Fillable 150 Des Moines Street Des Moines, IA 50309-1836 (Office of the Chief Information Officer)

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150 Des Moines Street Des Moines, IA 50309-1836 (Office of the Chief Information Officer)

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Type of Inspection:
Annual Inspection Re-inspection Division of Labor
Iowa Division of Labor
Amusement Ride Safety
150 Des Moines Street
Des Moines, IA 50309-1836
Phone: 515-725-5612/515-725-5608
Fax: 515-242-5076
amusement@iwd.iowa.gov
amusement.iowa.gov
Complete a separate form for each inflatable, blower, and generator then submit it the Division of Labor.
Inflatable Amusement Device Inspection Report
FOR OFFICE USE ONLY
Permit #:
Sticker #:
Inspection Date:
Repair Due Date:
Show name
Owner’s name
Email address
City
State
Zip
Owner’s phone number
Owner’s mobile number
Owner’s fax number
Location of inspection (address, city and zip)
Manufacturer
Name of device (Ex: ninja jump, generator 1, blower B)
Serial number
Name of trained operator
Date of training
02.02.2020
100-005
Inspection Codes
S = Satisfactory US = Unsatisfactory – Safety Order issued C = Corrected on Site NA = Not Applicable
Generator: Condition Grounding Ground Fault Protection
Fueling Location Fire Extinguisher
Extension Cords: Grounding Proper Size Setup Location (suitability)
Blower: Plug Ground Guarding Placement
Ground Fault Protection
Inflatable: Placement Stitching Condition Tie Downs
Staked Weighted
Operations: Safety Rules Posted Attendant on Duty Operations Manual Available
Trained Operator on Duty
Signature of Owner or Authorized Representative Date Signature of Owner Designated Inspector Date
Equal Opportunity Employer/Program
Auxiliary aids and services are available upon request to individuals with disabilities.
For deaf and hard of hearing, use Relay 711.
I certify that the information on this report is true and accurate to the best of my knowledge.
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150 Des Moines Street Des Moines, IA 50309-1836 (Office of the Chief Information Officer)

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Completed 13 August 2020

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