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D. Number Location of Escalator Rated Load Speed Inspected By DLT Account Number Phone Last Inspection RI License No. Elevator Co. DLT-L-133 2/05 Department of Labor and Training - Division of Occupational Safety - Elevator Unit ESCALATOR INSPECTION CHECK LIST Date State I. Signature Signature of person interviewed SAFETY TEST INFORMATION Annual Key Code No deficiencies Needs repair - NR ESCALATOR--EXTERNAL General fire protection Geometry Stop switch Handrails Entrance and egress ends Lighting Caution signs Combplate Deck barricade Steps and upthrust device Operating devices Skirt obstruction devices Handrail-speed monitoring device Rolling shutter device Balustrades Ceiling intersection guards Step/skirt clearance panels and performance index Outdoor protection Not applicable - NA Machinery space access lighting receptacle and condition Controller and wiring Drive machine and brake Speed governor Broken drive chain and disconnected motor device Reversal stop switch Broken step chain device Step upthrust device Missing step device Step level device Steps step chains and trusses Code data plate Response to smoke detectors CODE VIOLATIONS Per R*I. G*L* 23-33-24 violations must be abated within 30 days from the above inspection date. 1 COPY - ELEVATOR CO. Signature Signature of person interviewed SAFETY TEST INFORMATION Annual Key Code No deficiencies Needs repair - NR ESCALATOR--EXTERNAL General fire protection Geometry Stop switch Handrails Entrance and egress ends Lighting Caution signs Combplate Deck barricade Steps and upthrust device Operating devices Skirt obstruction devices Handrail-speed monitoring device Rolling shutter device Balustrades Ceiling intersection guards Step/skirt clearance panels and performance index Outdoor protection Not applicable - NA Machinery space access lighting receptacle and condition Controller and wiring Drive machine and brake Speed governor Broken drive chain and disconnected motor device Reversal stop switch Broken step chain device Step upthrust device Missing step device Step level device Steps step chains and trusses Code data plate Response to smoke detectors CODE VIOLATIONS Per R*I. G*L* 23-33-24 violations must be abated within 30 days from the above inspection date. 1 COPY - ELEVATOR CO.

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