Download OL 221A, Safety Inspection Report and more Summaries Business in PDF only on Docsity! ae A Public Service Agency SAFETY INSPECTION REPORT VEHICLE USED FOR INSTRUCTION [DRIVING SCHOOL NUMBER ‘SCHOOL/INDEPENDENT INSTRUCTOR: DATE OF INSPECTION ADDRESS: INSTRUCTOR NUMBER INSURANCE POLICY NUMBER MAKE OF VEHICLE BODY TYPE YEAR MODEL LICENSE PLATE NUMBER: VEHICLE REGISTERED OWNER REGISTRATION EXPIRATION DATE. VEHIGLE IDENTIFICATION NUMBER NOTE: A check in the “yes” column indicates that the item i is a part of or attached to the automobile, that it meets legal requirements and is in safe condition or operating order. Remarks should be entered in the space provided or on the reverse side of the form, if necessary. EQUIPMENT YES | NO REMARKS 1. Foot brakes (check stopping—at 20 mph passenger vehicles must be capable of stopping within 25 feet.) 2. Emergency brakes (engine stall test) 3. Steering Mechanism 4. Windshield 5. Rear view window and other glass 6. Windshield wipers 7. Headlights 8. Tail lights 9. Turn indicator lights 10. Stop lights 11. Frontseat adjustment mechanism 12. Doors (open, close, lock) 13. Horn 14. Speedometer 15. Bumpers 16. Muffler and exhaust system TREAD DEPTH 17. Condition of tires LF RF LR RR Spare 18. Interior and exterior rear view mirrors 19. Safety belts (for students and instructor) 20. Foot Brake (right side of right floor) 21. Rear View Mirror (inside on right side of vehicle) CERTIFICATION: CERTIFICATION: (Must be completed by a facility that is licensed by the Bureau of Automotive Repair.) | certify (or declare) under penalty of perjury under the laws of the State of California that the foregoing is true and correct. | further certify that | have inspected and tested each of the above items on this vehicle and have found them to be as shown. | certify (or declare) under penalty of perjury under the laws of the State of California that the foregoing is true and correct. | further certify that the above described vehicle is in conformance with Section 11109 CVC, which states: “Every licensee under this chapter shall maintain all vehicles used in driver training in safe mechanical condition at all times.” | also certify that vehicle insurance as defined in Section 11103 CVC, will be maintained SIGNED and proof of coverage will be carried in the vehicle being used for behind the wheel instruction and that the vehicle registration NAME OF FIRM INSPECTING VEHICLE BARLIGENSE # is current and will be maintained per Section 4000(a) CVC. BUSINESS ADDRESS SIGNATURE (School Owner, Operalor or Independent instructor) DATE OL 221 AUTOMOBILE (REV. 7/2007) WWW
