ANNUAL VEHICLE INSPECTION REPORT
VEHICLE HISTORY RECORD
REPORT
FLEET UNIT NUMBER
NUMBER
DATE
MOTOR CARRIER OPERATOR
INSPECTOR'S NAME (PRINT OR TYPE)
ADDRESS
THIS INSPECTOR MEETS THE QUALIFICATION REQUIREMENTS IN SECTION 396.19.
YES
CITY, STATE, ZIP CODE
VEHICLE IDENTIFICATION ( ) AND COMPLETE
LIC. PLATE NO.
VIN
OTHER
VEHICLE TYPE
INSPECTION AGENCY/LOCATION (OPTIONAL)
TRACTOR
TRAILER
TRUCK
(OTHER)
VEHICLE COMPONENTS INSPECTED
NEEDS REPAIRED
NEEDS REPAIRED
NEEDS REPAIRED
OK
ITEM
OK
ITEM
OK
ITEM
REPAIR
DATE
REPAIR
DATE
REPAIR
DATE
1. BRAKE SYSTEM
4. FUEL SYSTEM
9. FRAME
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
c. Adjustable Axle
d. Brake Hose
attached
Assemblies (Sliding
e. Brake Tubing
5. LIGHTING DEVICES
Subframes)
f. Low Pressure Warning
All lighting devices and
10. TIRES
Device
reflectors required by Section
a. Tires on any steering axle
g. Tractor Protection Valve
393 shall be operable.
of a power unit.
h. Air Compressor
6. SAFE LOADING
b. All other tires.
i. Electric Brakes
a. Part(s) of vehicle or
11. WHEELS AND RIMS
j. Hydraulic Brakes
condition of loading such
a. Lock or Side Ring
k. Vacuum Systems
that the spare tire or any
b. Wheels and Rims
part of the load or dunnage
c. Fasteners
2. COUPLING DEVICES
can fall onto the roadway.
d. Welds
a. Fifth Wheels
b. Protection against shifting
12. WINDSHIELD GLAZING
b. Pintle Hooks
cargo
Requirements and exceptions
c. Drawbar/Towbar Eye
7. STEERING MECHANISM
as stated pertaining to any
d. Drawbar/Towbar Tongue
a. Steering Wheel Free Play
crack, discoloration or vision
e. Safety Devices
b. Steering Column
reducing matter (reference
f. Saddle-Mounts
c. Front Axle Beam and All
393.60 for exceptions)
Steering Components
13. WINDSHIELD WIPERS
3. EXHAUST SYSTEM
Other Than Steering
Any power unit that has an
a. Any exhaust system
Column
inoperative wiper, or missing
determined to be leaking at
d. Steering Gear Box
or damaged parts that render
a point forward of or directly
e. Pitman Arm
it ineffective.
below the driver/sleeper
f. Power Steering
List any other condition which may
compartment.
g. Ball and Socket Joints
prevent safe operation of this
b. A bus exhaust system
h. Tie Rods and Drag Links
vehicle.
leaking or discharging to
i. Nuts
the atmosphere in violation
j. Steering System
of standards (1), (2) or (3).
8. SUSPENSION
c. No part of the exhaust
a. Any U-bolt(s), spring
system of any motor vehicle
hanger(s), or other axle
shall be so located as
positioning part(s) cracked,
would be likely to result in
broken, loose or missing
burning, charring, or
resulting in shifting of an
damaging the electrical
axle from its normal position.
wiring, the fuel supply, or
b. Spring Assembly
any combustible part of the
c. Torque, Radius or Tracking
motor vehicle.
Components.
X
X
NA
INSTRUCTIONS: MARK COLUMN ENTRIES TO VERIFY INSPECTION:
OK,
NEEDS REPAIR,
IF ITEMS DO NOT APPLY,
REPAIRED DATE
CERTIFICATION: THIS VEHICLE HAS PASSED ALL THE INSPECTION ITEMS FOR THE ANNUAL VEHICLE INSPECTION REPORT IN
ACCORDANCE WITH 49 CFR 396.
© Copyright 1994 & Published by J. J. KELLER & ASSOCIATES, INC.• Neenah, WI 54957-0368
200-FS-C3
PRINTED IN THE U.S.A.
Rev. 3/94
ORIGINAL
ANNUAL VEHICLE INSPECTION REPORT
VEHICLE HISTORY RECORD
REPORT
FLEET UNIT NUMBER
NUMBER
DATE
MOTOR CARRIER OPERATOR
INSPECTOR'S NAME (PRINT OR TYPE)
ADDRESS
THIS INSPECTOR MEETS THE QUALIFICATION REQUIREMENTS IN SECTION 396.19.
YES
CITY, STATE, ZIP CODE
VEHICLE IDENTIFICATION ( ) AND COMPLETE
LIC. PLATE NO.
VIN
OTHER
VEHICLE TYPE
INSPECTION AGENCY/LOCATION (OPTIONAL)
TRACTOR
TRAILER
TRUCK
(OTHER)
VEHICLE COMPONENTS INSPECTED
NEEDS REPAIRED
NEEDS REPAIRED
NEEDS REPAIRED
OK
ITEM
OK
ITEM
OK
ITEM
REPAIR
DATE
REPAIR
DATE
REPAIR
DATE
1. BRAKE SYSTEM
4. FUEL SYSTEM
9. FRAME
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
c. Adjustable Axle
d. Brake Hose
attached
Assemblies (Sliding
e. Brake Tubing
5. LIGHTING DEVICES
Subframes)
f. Low Pressure Warning
All lighting devices and
10. TIRES
Device
reflectors required by Section
a. Tires on any steering axle
g. Tractor Protection Valve
393 shall be operable.
of a power unit.
h. Air Compressor
6. SAFE LOADING
b. All other tires.
i. Electric Brakes
a. Part(s) of vehicle or
11. WHEELS AND RIMS
j. Hydraulic Brakes
condition of loading such
a. Lock or Side Ring
k. Vacuum Systems
that the spare tire or any
b. Wheels and Rims
part of the load or dunnage
c. Fasteners
2. COUPLING DEVICES
can fall onto the roadway.
d. Welds
a. Fifth Wheels
b. Protection against shifting
12. WINDSHIELD GLAZING
b. Pintle Hooks
cargo
Requirements and exceptions
c. Drawbar/Towbar Eye
7. STEERING MECHANISM
as stated pertaining to any
d. Drawbar/Towbar Tongue
a. Steering Wheel Free Play
crack, discoloration or vision
e. Safety Devices
b. Steering Column
reducing matter (reference
f. Saddle-Mounts
c. Front Axle Beam and All
393.60 for exceptions)
Steering Components
13. WINDSHIELD WIPERS
3. EXHAUST SYSTEM
Other Than Steering
Any power unit that has an
a. Any exhaust system
Column
inoperative wiper, or missing
determined to be leaking at
d. Steering Gear Box
or damaged parts that render
a point forward of or directly
e. Pitman Arm
it ineffective.
below the driver/sleeper
f. Power Steering
List any other condition which may
compartment.
g. Ball and Socket Joints
prevent safe operation of this
b. A bus exhaust system
h. Tie Rods and Drag Links
vehicle.
leaking or discharging to
i. Nuts
the atmosphere in violation
j. Steering System
of standards (1), (2) or (3).
8. SUSPENSION
c. No part of the exhaust
a. Any U-bolt(s), spring
system of any motor vehicle
hanger(s), or other axle
shall be so located as
positioning part(s) cracked,
would be likely to result in
broken, loose or missing
burning, charring, or
resulting in shifting of an
damaging the electrical
axle from its normal position.
wiring, the fuel supply, or
b. Spring Assembly
any combustible part of the
c. Torque, Radius or Tracking
motor vehicle.
Components.
X
X
NA
INSTRUCTIONS: MARK COLUMN ENTRIES TO VERIFY INSPECTION:
OK,
NEEDS REPAIR,
IF ITEMS DO NOT APPLY,
REPAIRED DATE
CERTIFICATION: THIS VEHICLE HAS PASSED ALL THE INSPECTION ITEMS FOR THE ANNUAL VEHICLE INSPECTION REPORT IN
ACCORDANCE WITH 49 CFR 396.
© Copyright 1994 & Published by J. J. KELLER & ASSOCIATES, INC.• Neenah, WI 54957-0368
200-FS-C3
PRINTED IN THE U.S.A.
Rev. 3/94
ORIGINAL
