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