Fillable Minnesota Vehicle Periodic Inspection Form 2019

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Minnesota Vehicle Periodic Inspection Form 2019

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The Minnesota Vehicle Periodic Inspection Form 2019 form is 2 pages long and contains:

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Country of origin: US
File type: PDF

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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.) Adjustment 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 CROSS 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
1
3. WIPERS/WASHER & DEFROSTERS
c. Securement of Tank
1
4. MOTORCOACH SEATS
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 (02/21/2019)
MINNESOTA
PERIODIC VEHICLE INSPECTION REPORT
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signature
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PERIODIC VEHICLE INSPECTION INFORMATION FORM
Date: Time: Veh. Lic.# Decal #
Inspector
Name:
BRAKE ADJUSTMENT
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
Chain Cable
Size:___________Grade:_______
Pivot Pin/Bracket:________________
Slider/Base:_____________________
Upper/Lower Halves: _____________
Tractor/Trailer used for Test
Lic. Plate: ____________ State:_____
5
th
Wheel Measurements (in.)
Motor Coaches
Emergency Exits/Push-out Windows:
Pass Fail NA
Notes:
I hereby certify the information contained herein is true and accurate: ________________________________________
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Minnesota Vehicle Periodic Inspection Form 2019

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Completed 23 September 2019

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