NEVADA DEPARTMENT OF 4600 Kietzke Lane, Suite F-151 1301 N.

Green Valley ,Suite 200

BUSINESS & INDUSTRY Reno, Nevada 89502 Henderson, Nevada 89074
Division of Industrial Relations Telephone: (775) 688-3750 Telephone: (702) 486-9054
MECHANICAL COMPLIANCE Fax: (775)688-1664 Fax: (702) 486-9176
SECTION [email protected] [email protected]

Periodic Inspection and Test for Escalator & Moving Walk

ASME A17.1 Section 8.11.4.1
Building Name Owners Name State # NV
Street Address Address
City, State, Zip City, State, Zip

1 Type: Escalator: Moving Walk:

2 Normal Direction of Travel: Up Down
Is test
8.11.4.1 Periodic Inspection and Test Requirements: Date of Test:
satisfactory?
3 General Fire Protection (Items 7.1 and 9.1) Yes No n/a
4 Geometry (Items 7.2 and 9.2) Yes No n/a
5 Handrails (Items 7.3 and 9.3) Yes No n/a
6 Entrance and Egress (Items 7.4 and 9.4) Yes No n/a
7 Lighting (Items 7.5 and 9.5 Yes No n/a
8 Caution Signs (Items 7.6 and 9.6) Yes No n/a
9 Combplate (Items 7.7 and 9.7) Yes No n/a
Deck Barricade Guard and Antislide Devices
10 Yes No n/a
(Items 7.8 and 9.8)
11 Steps and Treadway (Items 7.9 and 9.9) Yes No n/a
12 Operating Devices (Items 7.10 and 9.10) Yes No n/a
13 Skirt Obstruction Devices (Item 7.11) Yes No n/a
14 Handrail Entry Device (Items 8.13 and 10.13) Yes No n/a
15 Egress Restriction Device (Items 7.13 and 9.13) Yes No n/a
16 Speed (Items 7.14 and 9.14) Yes No n/a
17 Balustrades (Items 7.15 and 9.15) Yes No n/a
18 Ceiling Intersection Guards (Items 7.16 and 9.16) Yes No n/a
19 Skirt Panels (Items 7.17 and 9.17) Yes No n/a
20 Outdoor Protection (Items 7.18 and 9.18) Yes No n/a
Machine Space Access, Lighting, Receptacle & Condition
21 (remote machine rooms) ( Items 8.1 & 10.1) Yes No n/a
22 Additional Stop Switch(es) (Items 8.2 and 10.2) Yes No n/a
23 Controller and Wiring (Items 8.3 and 10.3) Yes No n/a
24 Code Data Plate (2.23.2) (Items 8.14 and 10.14) Yes No n/a
25 Section 8.6.1.7.2 (Periodic test record in the form of tags) Yes No n/a
Is Step/Skirt testing required? If yes, fill out the
26 Yes No
attached test form (Page 2 of 2)
Is test satisfactory and in accordance with the code in effect at time of original installation Yes No
27
and/or alteration: If no, state reason:
If test(s) proved unsatisfactory, indicate the reason and provide a written statement as to why the unit failed. The
statement must be filed with the MCS immediately. THE UNIT MAY NOT RETURN TO SERVICE IF ANY SAFETY
DEVICE FAILED unless the device was repaired and successfully re-tested.
The Above Tests Were Performed In Compliance With ASME A17.1 and NAC455C. 400-528 & Section 2 to 14
Firm Performing Tests Date of Test
Notes:
Print Name / License No./ Signature of Person Performing Print Name / License No./ Signature of Person Witnessing Tests
Tests

This report shall be filed with the Mechanical Compliance Section within ten (10) days of completion of all tests.
This report shall be submitted every six (6) months.

Page 1 of 2 Semi-Annual Inspection Rev. (4/17/17)

 ASME A17.1 – 8.6.15.19 & 8.6.8.3 Step/Skirt Performance Index & 8.6.8.15.20 Clearance
Between Step and Skirt (Load Gap).

State No. NV______________

Rated Speed: fpm. Capacity: lbs. Normal Direction of travel: Up Down

1. ASME A17.1 8.6.8.15.19 Step/Skirt Performance Index: The escalator skirt shall not be cleaned, lubricated, or
otherwise modified in preparation for testing. The escalator instantaneous step/ skirt index measurements shall
be recorded at intervals no larger than 150 mm (6 in.) from each side of two distinct steps along the inclined
portion of the escalator, where the steps are fully extended. Test steps shall be separated by a minimum of 8
steps.
Step 1 Left: Right: Step 2 Left: Right:
2. ASME A17.1 8.6.8.15.20 Clearance between Step and Skirt (Loaded Gap). Loaded gap measurements shall
be taken at intervals not exceeding 300 mm (12 in.) in transition region (8.6.8.2 & .3) and before the steps are
fully extended. These measurements shall be made independently on each side of the escalator.
Top Landing Left: Right: Bottom Landing Left: Right:
3. Skirt deflector brushes to be installed? : Yes No

NOTES:__________________________________________________________________________________
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The Above Tests Were Performed In Compliance With ASME A17.1 and NAC455C. 400-528 & Section 2 to 14
Firm Performing Test Date of Test

(Print) Name/ License No/ and Signature of Person (Print) Name, License No. and Signature of Person
Performing Tests Witnessing Tests

Page 2 of 2 Semi-Annual Inspection Rev. (4/17/17)