Fillable MINNESOTA PERIODIC VEHICLE INSPECTION REPORT (Minnesota)

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MINNESOTA PERIODIC VEHICLE INSPECTION REPORT (Minnesota)

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Country of origin: US
File type: PDF

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MINNESOTA
PERIODIC VEHICLE INSPECTION REPORT
1. Date mm/dd/yyyy
2.Insp.Location (Street Address)
3. City, State ZIP
4.Time in
5. Time Out
am
pm
am
pm
6.Veh Make
7.Year
9. Unit #
10.Odometer
11.Lic#
12.State
13. Decal #
C
H
14.Owner Name
15.Owner Street Address
16. City, State, ZIP
17.Carrier Name
18.Carrier Street Address
19.City, State, ZIP
20.Owner USDOT#
21. Carrier USDOT#
22.Inspector Name
23.Inspector #
PASS
FAIL
N/A
PASS
FAIL
N/A
1. BRAKE SYSTEM 5. LIGHTING DEVICES
a. Service Brakes
a. Headlamps
1.) Adjustmen
t
b. Tail lamps
2.) Pads c. Brake lamps
b. Parking Brake
System
d. Turn Signals
c. Brake Drum or Rotors e. Marker/ID/Clearance Lamps
d. Brake Hose f. Conspicuity
Tape/Reflectors
e. Brake Tubing
6. SAFE LOADING
f. Low Pressure/Vacuum/or Low Air Warning Device
7. STEERING MECHANISM
g. Tractor Protection Valve a. Steering Wheel Free Play(Lash)
h. Air Compressor b. Steering Column
i. Electric Brakes
c. Front Axle Beam & All Components Other Than Steering
j. Hydraulic Brakes ( including power assist) d. Steering Gear Box Column
k. Vacuum Systems e. Pitman Arm
l. ABS f. Power Steering
1. Power Unit Warning Light g. Ball & Socket Joints
2. Towed Unit Warning Light h. Tie Rods & Drag Link
3. System malfunction i. Nuts
m. Automatic Slack Adjusters
j. Steering System
n. Breakaway Brakes - trailers
8. SUSPENSION
a. U-Bolts
2. COUPLING DEVICES
b. Spring Assembly
a. 5
th
Wheel & Mounting/King Pin c. Torque, Radius, or Tracking Components
b. Pintle Hooks & Mounting Ball hitch
9. FRAME/INCLUDING CRO
SS FRAMES
c. Drawbar /Towbar Eye
a. Frame Members
d. Drawbar/Towbar Tongue b. Tire & Wheel Clearance
e .Safety Devices (chains, cables, hooks)
c. Adjustable Axle Assemblies (sliding subframes)
& Locking Devices - Trailer Only
f. Saddle Mounts
10. TIRES
g. Locking Devices
11. WHEELS & RIMS
a. Lock or Slide Ring (Split Rim)
3. EXHAUST SYSTEM
b. Wheels & Rims
c. Fasteners (lugs)
4. FUEL SYSTEM
d. Welds
a. Visible Leak
12. WINDSHIELDS/Glazing
b. Fuel Cap
13. WIPERS/WASH
ER & DEFROSTERS
c. Securement of Tank
14. MOTORCOACH SEAT
S
15. REAR VISION MIRRORS 19. REAR END PROTECTION
16. HORN 20. CAB & BODY COMPONENTS
17. FIRE EXTINGUISHER 21. WHEEL FLAPS
18. EMERGENCY WARNING DEVICES 22. DRIVELINE/DRIVESHAFT
THIS VEHICLE IS IN COMPLIANCE WITH 49 CFR 396.17 APPENDIX G
I hereby certify that the above information is true and accurate.
Inspector Signature
This is the only vehicle inspection form approved by the Minnesota State Patrol (01/01/2022)
Y N
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PERIODIC VEHICLE INSPECTION INFORMATION FORM
Date: Time: Veh. Lic.# Decal #
Inspector
Name:
BRAKE ADJUSTMENT/BRAKE TYPE
Right
Chamber Type/Size
Pushrod Stroke (in.)
Axle # 1 2 3 4 5 6 7
Left
Pushrod Stroke (in.)
Chamber Type/Size
TIRE INFORMATION
Right
Tire Size
Outside
Min. Tread
PSI
Inside
Min. Tread
PSI
Axle # 1 2 3 4 5 6 7
Left
Inside
Min. Tread
PSI
Outside
Min. Tread
PSI
Tire Size
Brakes
Electric Surge
Controller
Make/Model:____________________
Tow Vehicle
Lic. Plate: ____________ State:______
GVWR:______________
Trailer
Lic. Plate:____________ State:______
GVWR:______________
Steering
Wheel diameter: ________________
Free Play (in.):___________________
Tractor Protection Valve
Activates at (PSI): _______________
Safety Devices GVWR__________
Chain Cable
Size:___________Grade:_______
5
th
Wheel Measurements (in.)
Pivot Pin/Bracket:________________
Slider/Base:____________________
Upper/Lower Halves:_____________
Trailer used for Test
Lic. Plate: ____________ State:_____
Motor Coaches
Emergency Exits/Push-out Windows:
Pass Fail NA
Notes/21-day temporary license number:
I hereby certify the information contained herein is true and accurate:
________________________________________
Inspector signature
This is the only vehicle inspection form approved by the Minnesota State Patrol (01/01/2022)
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MINNESOTA PERIODIC VEHICLE INSPECTION REPORT (Minnesota)

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Completed 5 February 2022

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