ESCORTS KUBOTA LTD.

FonaatNo QA-FRM-017
SPECIAL APPORVAI, REQl"EST FORM Iff. Date 25.01.2023

Special approval Request Not>e: This request shall not be epplied to perts 11 1~ ~lemeted on
2 WII be imc,temented on
I Date l Cneckedby
Rn.No

Ab••Y
00

Interim

SlFPUER/ SCM/ NPD KMC/ Souroinc

l - l/11/1m4 I I
Rl~7~dv=::
Datt:

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No.
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Corrective
I Hie
-
10on_,yname
l"l,.,l. ,. . -
Action
Date 2, J~'f Cheeked by
IName of Requester
1Name ol Person raponsille for OA '"""'"A
'9M~-@e ft etliii,L.. IOtte of let Dtliv. eftM P......-Actiol'I ie hplemerud
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7

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DESCRPTlON OF DEVIATION r.-tbl'\'l L""HJ I €."- A6~ \ "I /\ll-
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I q~ al t ,fi..ivtA. 't,,;,. I ..
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!Part & Re~.
[Modal Affected:
Part OHc,;ption
FT co.w,y
AA ~' ~Dl f C -m L~ •
m" -~...ui DI\ ffK
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1st Prue!. 2
1st
p5::;;" 4 Seniice Parts I CKD I SKD '
--_!!I)-, l
.-1 Comment

1::.
Place I Aaoehi,is.... I from EKL
AsNfflbly I ln111ec:tion I S~ier END R&D
l ConcltioNI Aw,.,.,., jo1 'j:..i

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y,__ of Prod. Lat •2.,..o ' Dumion Date
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F ~ nruol rr... -.. ·IPIRheMOnle,N o.o,
B<L Prod. Month

[Asttietic
I
-_.._ I
DEVIATION Fitment
IFunc:tionel
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AfFEC'TB)
I Metallursicel

1 IW. request EKL to . _ the perts without mendnc/reworlcinr the defect

,......_._ ~,. I I
I IW. - a t EKL to edopt the perts after mencfmc/rewori<inc the defect ilustr-.tad

(Debils of defect> Please Expjejn the dafact by darr- as

Imuch as you cen.
as below

<Details of -inn•nt>
LJ. ReQuelltM
Sicnature

INerMot~
1 1
...... ,,,-~Aiii,,,,J'. Ra-o,Dl9tie ..... to _ _ _ _ _ _
_ _ _ _ _ ,_ _ _ . , . _ _ t o _ o . t

Dept. of EKL
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Re...lt r,/ doublr-ohec:k of f!!'!S 1Nt - IUlpct ID,<
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1' ffi It 01:11 Allic:,t
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I
Request
fc I>
Sirnature
T Om

0•'J"-1•2.
o.go
Ec2 ~,-..-( I ... Reply to - ~ fa, Oewiation-
Accordinr to your request. EKL herwby reply as follows. The instructions st.el be ~
0·'3 -,.1. o1,u....-vd ;
• d by Requntor Dept.

- ~Bo
I
.\. , I ~~on 1:1 N=~ I
l J
fle&.No.
:::::::........ Approval by l Du l
WHY it occurred WHY it was NOT found before de&very Inspection 0.pl Sip,ature
1. Puttin1 an identification _,_ en Doviat,cn ltam ,_.... -...-
/,
........ 2. Keopins tnl reconl of Macl,;no Serial No.
lnetrvc1ion 3. Submi11ion of inap. data (a!le, the action)
I
r ........
........ .... ,_.,.
I Not ....,..s
4. Othtra <Porta to bo checJo.ed, etcJ
,r (1) I., COM of "Conditic,,\al Apo,ovol". make...,. that in11Nctiona.,. fulfilled
w ~ ..... that-oftno- wil-.twilhin 3-•

Reason of
the defect
·_·\\,. (h ...
v""'"" ;p"-
-~
M•d>ne Sen.I No.I
D=: I
7 S-INo. l This - - shel be filled i n ~ ~ l>eflt

Checked by

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t,,-ctio,,

I E~Ooot
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Ori&inated BY
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Verified By
Approved By
l.aad Central
HNd Mf&_&Plant Enlineerina Head SCM HNd Sourcinc
Labs&QMS HNd kMC NPO HudDnip Heed Quality Control
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