Performance Work Statement Attachment IV - Hydraulic Elevator Test

5648325476250002349500
Fort Huachuca, Directorate of Public Works
Periodic tests of Hydraulic Elevators
Check List

Test Performed: Bi-Annual ☐ Annual ☐ Five (5) Year ☐
Test Performed: Bi-Annual ☐ Annual ☐ Five (5) Year ☐

Building & Unit Information
Building Name
Owner/Building Management Name
Building Address
Unit Identification / Unit PIN

BI-ANNUAL INSPECTIONS

ASME Section
Pass
Fail
N/A
Static and relief pressure test
1005.1

Safety test
1002.1

ANNUAL INSPECTIONS

ASME Section
Pass
Fail
N/A
Relief Valve Setting and System Pressure Test
8.11.3.2.1

Hydraulic Cylinders and Pressure Piping
8.11.3.2.2

Normal Terminal Stopping Devices
8.11.3.2.3(a)

Governors, Over speed Switch, and Seals
8.11.3.2.3(b)

Safeties
8.11.3.2.3(c)

Oil Buffers
8.11.3.2.3(d)

Firefighter’s Emergency Operation
8.11.3.2.3(e)

Standby Power Operation
8.11.3.2.3(f)

Power Operations of Door System
8.11.3.2.3(g)

Emergency Terminal Speed Reducing Devices
8.11.3.2.3(h)

Low Oil Protection Operation
8.11.3.2.3(i)

Flexible Hose and Fitting Assemblies
8.11.3.2.4

Pressure Switch
8.11.3.2.5

FIVE (5) YEAR INSPECTION

ASME Section
Pass
Fail
N/A
Car and Counterweight Safeties
8.11.3.4.1

Governors
8.11.3.4.1

Oil Buffers
8.11.3.4.1

Coated Ropes
8.11.3.4.2

Wire Rope Fastenings
8.11.3.4.3

Plunger Gripper
8.11.3.4.4

Over speed Valves
8.11.3.4.5

The Above Tests Were Performed In Compliance With ASME A17.1 Firm Performing Test/Service
Elevator Contractor Number

Firm Address
Firm City/State/Zip
Name of Mechanic Performing Test/Service
Date of Test/Service