CA 90 Day/DOT Annual Inspection Form
No Problem Found
Repairs Needed
Repairs Completed
Unit Number
RO Number
Date
LS Stroke
LS Thickness
RS Stroke
RS Thickness
LFD Stroke
LFD Thickness
RFD Stroke
RFD Thickness
LRD Stroke
LRD Thickness
RRD Stroke
RRD Thickness
LS Pad
LS Rotor
RS Pad
RS Rotor
LFD Pad
LFD Rotor
RFD Pad
RFD Rotor
LRD Pad
LRD Rotor
RRD Pad
RRD Rotor
LS Pressure
LS Tread Depth
RS Pressure
RS Tread Depth
LFO Pressure
LFO Tread Depth
LFI Pressure
LFI Tread Depth
RFI Pressure
RFI Tread Depth
RFO Pressure
RFO Tread Depth
LRO Pressure
LRO Tread Depth
LRI Pressure
LRI Tread Depth
RRI Pressure
RRI Tread Depth
RRO Pressure
RRO Tread Depth
CERTIFICATION: THIS VEHICLE WAS INSPECTED IN ACCORDANCE WITH SECTION 396.17-23, APPENDIX G OF THE FEDERAL MOTOR CARRIER’S SAFETY REGULATION.
Inspector Name
Signature
Date
Technician Name
Signature
Date
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