DELIVERY REPORT

R Warranty Registration
Executed report must be submitted via NicSmart within 15 days of delivery to customer.

Delivering Dealer: SERMUR S.R.L

Dealer Name:________________________________________________________ Dealer #: _________________
CALLE PEDRO CABALLERO #2037
Address: ____________________________________________________________
Clear Form
IRPAVI
____________________________________________________________
LA PAZ, BOLIVIA - SOUTH AMERICA
____________________________________________________________
LA PAZ
City:_______________________________________ State:__________________ Zip Code: ________________

Forklift Truck Information: Subcomponent assembly serial numbers - if not applicable provide N/A as data
FHG25T3
Equipment Model _____________________ Equipment Serial 2E530393
_____________________ Hour Meter ____________________
Mast Model VFHM480-2NS
_____________________ Mast Serial 4E3197
_____________________ 2N574988
Transmission S/N ____________________
Engine S/N GK25-065360
_____________________ Drive Motor 1 S/N _____________________ Drive Motor 2 S/N ____________________
Final Drive 1 S/N _____________________ Final Drive 2 S/N _____________________ Lift Motor S/N ____________________
VCM or Pump Controller S/N _________________________________ ECM or Traction Controller S/N _____________________________
Additional Item #1____________________________________________ Additional Item #2 _________________________________________

Dealer Pre-Delivery Service: Prior to delivery of this Forklift , the following items were checked in accordance with page 2 and corrective action
was taken as necessary.
✔ Visual Inspection ✔ Test Drive and Operation ✔ Wheels and Tires ✔ Brake System
✔ Transmission ✔ Hydraulic System ✔ Electrical System ✔ Lift Mechanism
✔ Final Drive ✔ Cooling System (I.C. Only) ✔ Engine (I.C. Only) ✔ Chassis Lubrication
✔ Dealer Stock Storage Requirement
PDI Technician Notes: ___________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
PDI Technician Name: _______________________________________
13/03/2020
Date Completed: ___________________________________________ Technician Signature: _______________________________________

Delivered to Customer Location: Customer Review:

C.B.N. S.A.
Customer Name: _________________________________________
AV. 6 DE MARZO (CD)
Address: ________________________________________________
________________________________________________
________________________________________________
EL ALTO
City: _____________________ LP Zip Code: _________
State:_____
Country: __BOLIVIA
________________ SIC Code: ____________________
Decision Maker: __________________________________________
Decision Maker Title: ______________________________________
+591 765 58323
Phone Number: __________________________________________
E-mail Address: __________________________________________
Upon the delivery of this lift truck the following items were provided by
delivering dealer and and reviewed with customer.
✔ Operator’s Manual
✔ Warranty Certificate, Terms and Conditions
✔ Availability of options/Additional Warning Devices
✔ Safety devices, Safety checks and operation practices
✔ Operator Training Requirements
Will a Planned Maintenance Program be used? Yes No
Who will be responsible for Planned Maintenance?
Dealer Customer Non-OEM Service Other

Forklift Acceptance / Warranty Section - Date and Sign:

CUSTOMER - DEALER -
Customer representative Name: __BERNARDO ARCE
___________________________ VICTOR HUGO MURILLO MEDINA
Dealer Representative: _____________________________________
(Please Print) (Please Print)
GENERAL MANAGER
Title: _____________________________________________________ Title: _____________________________________________________

Customer’s Signature: ______________________________________ Dealer Rep Signature: ______________________________________

23/12/2019
Date Accepted: ____________________________________________ 23/12/2019
Date Delivered: ____________________________________________
 R

Inspection items by ITA Truck class

Class 1 2 3 4 5 Class 1 2 3 4 5
Visual Inspection X X X X X Hydraulic System X X X X X
Warning Decals & Capacity Plate X X X X X Oil level X X X X X
Paint condition X X X X X Valve operation X X X X X
Covers / Access panel secured X X X X X Hoses/Tubes connections X X X X X
No missing or damaged parts X X X X X Electrical System X X X X X
All wires and harness connectors
No fluid leaks X X X X X X X X X X
properly secured
Limit switches adjusted and
Test Drive and Operation X X X X X X X X X X
operating correctly
Operator Presence System / Verify correct controller settings
X X X X X X X X X X
Handle Switch Etc... (VCM,Logic Controller ,etc.)
Alarms - Park Brake / Seat Belt X X X Review & Clear error codes X X X X X
Horn X X X X X Verify power cable connection torque X X X X X
Travel / Back Up alarm (if applicable) X X X X X Cooling fan operation X X X
Heat sink and vents clear
Lights- Head/Rev/Brake/Tail/Turn X X X X X X
of obstruction
Strobe Light (if applicable) X X X X X Lift Mechanism X X X X X
Meter Panel / MDI display & warnings X X X X X Lift Chains / Anchors X X X X X
Service & Park Brake operation X X X X X Rails / Rollers / Slides X X X X X
Steering operation X X X X X Mast Support Caps / Bolt torque X X X X X
Forward / Reverse Travel X X X X X Lift Cylinder Mounts / adjustment X X X X X
Lift, Tilt & Auxiliary Operation X X X X X Tilt Cylinder Mounts / adjustment X X X X X
Rated capacity X X X X X Carriage adjustment X X X X X
Operator Restraint X X X Attachment - operation (if applicable) X X X X X
Wheels & Tires X X X X X Load Backrest X X X X X
Drive and Steer Wheel and Tire condition X X X X X Locking / Retaining Hardware X X X X X
Caster Wheel condition and
X X X X X Lift Linkage and adjustment (low lift) X
height adjustment
Tire Pressure (if applicable) X X X Final Drive X X X X X
Load Wheel condition X X Housing / Mounting / Axle condition X X X X
Wheel Lug Nut torque verification X X X X X Fluid Level(s) X X X X
Brakes X X X X X Cooling System (I.C. Only) X X
Park Brake - Lever/Cables/Switch &
X X X Belt tension X X
operation effort
Stopping distance within specification X X X X X Coolant level X X
Electromagnetic Brake operation X X X Radiator clear of obstruction X X
Brake fluid level (if applicable) X X X Engine X X
Transmission X X Engine oil condition and level X X
Transmission oil condition and level X X Chassis Lubrication X X X X X
Lubricate chassis per model specific
Inching Pedal operation and adjustment X X X X X X X
service manual
Dealer Storage Requirement X X X X X

In the event a unit requires maintenance or restoration due to extended storage duration or conditons, it is the Dealer’s responsibility to maintain, refinish
and/or replace all parts necessary to bring the equipment back to UniCarriers factory standards. Please reference SB2016-338.

Additional customer comments: _____________________________________________________________________________

_____________________________________________________________________________
_____________________________________________________________________________

Additional dealer comments: _____________________________________________________________________________

_____________________________________________________________________________
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