Cal. Code Regs. Tit. 8, div. 1, ch. 3.2, subch. 2, art. 13, Plate 1
Current through Register 2024 Notice Reg. No. 50, December 13, 2024
(Sample format--IS 162)
| Equipment Operator: ___________________________ | ___________________________Owner: | |
| Address:___________________________ | ___________________________Address: | |
| Description and location of equipment inspected: __________________________________________________________ | ||
| ________________________________________________________________________________________________ | ||
| Manufacturer: ___________________________ | Model No.: ___________________________ | Serial No.: ___________________________ |
| Owner I.D.: ___________________________ | Rated Capacity: ___________________________ | |
| The following deficiencies were found to exist during the inspection, testing and/or examiantion of the above-referenced equipment on ________________________________________. | |
| Description of Condition to be Corrected | Verification Date and Signature |
| 1. | |
| 2. | |
| 3. | |
| 4. | |
| 5. | |
| 6. | |
| 7. | |
| 8. | |
| 9. | |
| (See attached sheet for additional items or descriptions, if any.) | |
A certificate to operate the above-referenced equipment will not be issued until the items noted herein are corrected and verified as such by the undersigned.
A copy of this Notice, as well as any subsequent verification of corrections, shall be sent, as required, to the Division of Occupational Safety and Health. Labor Code 7375 and Sections 344.6, et. seq. and 4884, et. seq. of Title 8 of the California Code of Regulations prohibit the operation of any crane or derrick subject to the certification requirements thereof to be operated without a valid certification issued by a Division-licensed certifier or approved surveyor.
| Licensed Certifier, Name:___________________________ | License No.:___________________________ |
| Address:___________________________ | |
| Approved Surveyor, Name:___________________________ | Title:___________________________ |
| Date:_______________ | Signature:___________________________ |
Cal. Code Regs. Tit. 8, div. 1, ch. 3.2, subch. 2, art. 13, Plate 1