‫الــفـــريــــق‬

‫الســتــشــــارات‬
‫الســـالمــــة‬ 004-IB

TEAM SAFETY CONSULTANTS

CERTIFICATE OF EXAMINATION AND TEST OF MOBILE CRANE

Job No.: Certificate No.:

Client Name & Address: Name & Address of Maker or Supplier of Equipment::

Location: Survey Requested by: Type of Inspection:

Serial Model No.: Year of Manufacture / Put Into Use:

Owner Distinguishing Mark/Plate No.: Type of Crane : Type of Boom:

Capacity: Make & Type of Derricking Interlock: Make & Type of Automatic Safe Load Indicator:

SAFE WORKING LOAD(S) (PROOF TESTING): (i) (ii) (iii) (iv)

In the case of a crane with a variable operating radius (including a crane with a derricking jib Length of Jib Radius Test Load Safe Working Load
or with inter-changeable jibs of different lengths), the safe working load at various radii of the (m) (m) (Tonne) (Tonne)
jib trolley or crab must be given in column (iv). Test loads at various radii should be given in
column (iii) and in the case of safe working load which has been calculated without the
application of test load “NIL” should be entered in that column.
Wire Rope Dia.: No’s of Ram:

No. of Falls/Reeve: Hook block Capacity:

Degree/Rotation: Counter Weight:

In case of a crane with a derricking jib or jibs the maximum radius at which the jib
or jibs may be worked in
Defects or Deficiencies Noted and Alterations or Repairs Required Before Putting
The Crane Into Service.
:.TSC Test Method No TSC Test Equipment No.: Reference Regulations:
BS 7121 – 2 – 1 : 2012
TSC/ITP/01 TSC/EQ/03, 05, 07, 10, 15, 28 BS 7121 – 2 – 3 : 2012
Date of Previous Test: Date of Inspection: Date of Issue: Date of Expiry:

*Certificate becomes invalid, if any alteration/major repair/modernization made on the Mobile Crane in which case it must be re-examined and re-tested.

THIS IS TO CERTIFY THAT the Undersigned, a competent representative, did, attend to examine this equipment in accordance to the aforementioned standard to ascertain
its safe working load and that the examination indicated that the said equipment has no indigenous injury or sighted deformation and the safe working load of the said
equipment as either identified or test proof loaded is shown. The equipment is satisfactory for its intended use within the limits specified and at the time of inspection was
found to be satisfactory for further use, provided there is continuous maintenance applied, implementation of our remarks & recommendations and qualified operators
employed.

Name and position of person who Authorized signatory authenticating

carried out the inspection and test: :this certificate

Eng. Mark Victorino Eng. Abdul Aziz

Inspection Engineer Technical Manager

CERTIFICATE is granted subject to the condition that is understood and agreed that nothing herein contained shall be deemed to relieve any designer, manufacturer, seller,
supplier, repairer or operator of any warranty, express or implied. This inspection is not intended as guarantee against failure or malfunction. Team Safety Consultants will not
be held responsible for any damage to the equipments or parts after examination or accident due to improper use. No liability for use, operation and for any hidden defects or
information related to the equipment and inspection done is assumed by the inspector or Team Safety Consultants. Any person not a party to the contract pursuant to which
this document is delivered may not assert claims against Team Safety Consultants for any liability arising out of errors or omissions which may be contained in said document

TSC-F-17A (Rev.20) (05/01/2022) Page 1 of 2

and in connection with any activities for which it may provide. This certificate shall not be reproduced except in the full without written approval of the Team Safety
Consultants and the receiving client.

TEAM SAFETY CONSULTANTS, TRADE LICENSE NO. 500714, AL-GARHOUD, P. O. BOX: 112349, DUBAI - UAE, TEL: 04-2828868, FAX: 04-2865265
EMAIL: info@teamsafetyconsultants.ae, WEBSITE: http://tsc-uae.ae/

Continuation of Job No.: Certificate No.:

FINDINGS SECTION
Findings Target Date:

Supplementary:
a. Periodic maintenance required as per the manufacturer instruction.
b. For safe operation, operator and others shall be follow the manufacturer safety instruction.
c. Competent / Certified person only allowed to operate this equipment.
d. Certified Lifting accessories are only allowed to use for lifting purpose.
e. Required / suitable PPE must be worn before use the equipment.
f. Equipment operation should be verified by the operator / maintenance team before starting the work and after completion of the work, If any fault observe do
not continue the work.
g. If any abnormal condition / sound observed from the equipment during the time of operation, the concerned person should be informed to the maintenance
provider, client, building maintenance and safety personnel.

Note:
a. In accordance with EIAC-RQ-IB-001, conditional based validity certificate is issued, Certificate become invalid in case of not rectify the finding within target date, in which case it
must be inspection again.
b. This is the client responsibility shall be respond / inform to TSC for the Re-inspection or submit the evidence within the target date given in the inspection certificate.
c. This is the client responsibility to adhere the supplementary points at all the time but not limited.

TSC-F-17A (Rev.20) (05/01/2022) Page 2 of 2