Free F621-055-000 test of escalator safety devices - Washington

Department of Labor and Industries Elevator Section PO Box 44480 Olympia WA 98504-4480 Phone: (360) 902-6130 FAX (360) 902-6132

TEST OF ESCALATOR SAFETY DEVICES
RESET

A licensed elevator mechanic shall perform this test once a year. A copy of this test shall be sent to the above address.
Building Name Address This escalator serves Year installed
1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18. 19. 20. 21. 22. 23. 24. 25. 26. 27. 28. 29. Brake Lining Condition: Broken Drive Chain Device: Broken Step Chain: Comb Step Impact Devices: Demarcation Lighting: Disconnected Motor Device: Drain in Bottom for Outside Escalators: Drive Chain Tension: Emergency Stop Buttons: Handrail Chain Tension: Handrail Entry Device: Handrail Monitoring Device: Landing Plant Switches: Lockable Fused Disconnect or Circuit Breaker: Machine Room Cover Switches: Machine Room Light: Machine Room Stop Switches: Missing Step Device: Reversal Stop Device: Reverse Phase Relay: Rolling Shutter Device: Signage: Skirt Switches: Speed Governor: Step Chain Tension: Step Level Device: Step Rollers: Step Upthrust Devise: Top Bottom Tandem Operation Interlock Device:

Conveyance # City level to level in the State Zip+4 direction

LH Top Top Top Top

RH Bottom Bottom Bottom Bottom

LH

RH

LH LH

RH RH

Comments Name and elevator contractor's license # of firm making test Name and license # of elevator mechanic performing test Date of Test Date of Test

F621-055-000 test of escalator safety devices 7-03