COLORADO PUBLIC UTILITIES COMMISSION

ANNUAL VEHICLE INSPECTION REPORT VEHICLE HISTORY RECORD

REPORT NUMBER

Date

Time

UNIT NO. Inspection Agency/Location

Carrier's Company Name Address

Inspector's Name (Print or Type) This Inspector Meets the qualification requirements in Section 396.19 ( ) Yes

City

State

Zip Code

Plate

Make

VIN

Year

Vehicle Type (Circle One)

Taxi

Van/People Mover

Bus

Limousine

Truck

Trailer

State Tow Truck

Other

VEHICLE COMPONENTS INSPECTED OK

Needs Repaired Repair Date

Item

OK

Needs Repaired Repair Date

Item

OK

Needs Repaired Repair Date

Item

1. BRAKE SYSTEM

4. FUEL SYSTEM

a. Service Brakes

a. Visible Leak

a. Frame members

b. Parking Brake System

b. Fuel Tank Filler Cap Missing

b. Tire and Wheel Clearance

c. Brake Drums or Rotors

c. Fuel Tank Securely Attached

c. Adjustable Axle

d. Brake Hose

5. LIGHTING DEVICES

e. Brake Tubing

All lighting devices and reflectors

f. Low Pressure Warning

required by Section 393 shall be

Device g. Tractor Protection Valve

operable. 6. SAFE LOADING

9. FRAME

Assemblies (Sliding Subframes) 10. TIRES a. Tires on any steering axle of a power unit.

h. Air Compressor

a. Part(s) of vehicle or condition

i. Electric Brakes

of loading such that the spare

j. Hydraulic Brakes

tire or any part of the load or

k. Vacuum Systems

dunnage can fall onto the

b. Wheels and Rims

roadway.

c. Fasteners

2. COUPLING DEVICES a. Fifth Wheels

b. Protection against shifting

b. Pintle Hooks

cargo.

c. Drawbar/Towbar Eye

7. STEERING MECHANISM

b. All other tires. 11. WHEELS AND RIMS a. Lock or Side Ring

d. Welds 12. WINDSHIELD GLAZING Requirements and exceptions

d. Drawbar/Towbar Tongue

a. Steering Wheel Free Play

as stated pertaining to any

e. Safety Devices

b. Steering Column

crack, discoloration or vision

f. Saddle Mounts

c. Front Axle Beam and All

reducing matter (reference

3. EXHAUST SYSTEM

Steering Components Other

a. Any exhaust system determined to be leaking

Than Steering Column d. Steering Gear Box

393.60 for exceptions) 13. WINDSHIELD WIPERS Any power unit that has an

at a point forward of or

e. Pitman Arm

inoperative wiper, or missing

directly below the driver/

f. Power Steering

or damaged parts that render

sleeper compartment

g. Ball and Socket Joints

b. A bus exhaust system leaking or discharging to the atmosphere in violation of standards (1), (2) or (3). c. No part of the exhaust

List any other condition that

i.

may prevent safe operation of

Nuts

j. Steering System 8. SUSPENSION

or other axle positioning

vehicle shall be so located

part(s) cracked, broken, loose

as would be likely to result

or missing resulting in shifting

in burning, charring, or

of an axle from its normal

wiring, the fuel supply, or any combustible part of the motor vehicle.

this motor vehicle.

a. Any U-bolt(s), spring hanger(s)

system of any motor

damaging the electrical

it ineffective.

h. Tie Rods and Drag Links

position. b. Spring Assembly c. Torque, Radius or Tracking Components

Mark column entries to verify inspection: __X___ OK __X__ Need Repair __NA__ If Items Do Not Apply _____ Repair Date, As Applicable CERTIFICATION: THIS VEHICLE HAS PASSED ALL THE INSPECTION ITEMS FOR THE ANNUAL VEHICLE INSPECTION REPORT IN ACCORDANCE WITH 49 CFR PARTS 396-17 THROUGH 396-23.

g:\trn\ci forms\avir.xls .Jul14

* A copy of this report must be kept in the vehicle in accordance with 49 C.F.R. 396.17(c)