Hydraulic Elevators Periodic Safety Tests Declaration Form 1205

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BC Safety Authority New Westminster Office: 505 Sixth Street, Suite 200 New Westminster, BC V3L 0E1
Email:elevating.devices@safetyauthority.ca Website: www.safetyauthority.ca
Hydraulic Elevator Periodic Tests Declaration
The information on this form is collected to administer the provisions of the Safety Standards Act. If you have any questions about the collection and use of this information, contact the Records, Information & Privacy Analyst at 1-866-566-SAFE (7233).
Date: BCSA #: Building Name: Address: City: Owner: Has the Control Valve been replaced? Relief Bypass Pressure: psi Is the Working Pressure posted in M/R? Relief Valve Sealed? Yes □ No □ Over-speed Valve Sealed? Yes Yes
Elevator #: Class: Type: Speed:
# Floors: Passenger

□ Direct □ Hole-less □ Roped Hydraulic
□ □
No □
Hydraulic Tests
Was the Stop Ring engaged during relief pressure test? Yes Yes No □

No □

No □ N/A □
Is the Safety Valve Tag placed on controller in permanent way? Yes Type of Safeties: Type A Type of Governor:

No □ N/A □
Roped Hydraulic Tests

Type B
□ □

Sheave Friction Trip
Car Safeties visually inspected, cleaned, operated & sealed?
Car Governor visually inspected, cleaned, operated & sealed? Governor Tripping Speed: f/m Governor Pull through: On: Over-Speed Switch Tripping Speed: f/m Car Governor Tagged: Yes □ No □ Governor Rope Condition: Slack Rope Switch Tested: Yes □ No □
□ Yes □
□ No □
Contractor performing tests:
Mechanics name: Supervisors name: Signature: Signature:
  Where there is a conflict between this Guideline and the Act and Regulations the regulations shall prevail. 
Date: Date:
FRM‐1205‐01 (2009‐06‐10)