5803_ROSCANS_2012

WM Form 71 NORTH CAROLI TENT OF AGRICULTURE & CONSUMER SERVICES563
61
Revised 12/2004 INSR NO..
TANDARDS DIVISION,
DATE G? � 1 8 ! 50 Mail Service Center
Raleigh, NC 27699 t1050 °
County
v N . F gr.ALE TEST REPORT
_ OWNER' ADDRESS:
CITY: �.
ZIP CODE: PHONE PHONE NO
MAKE OF SCALE MODEL NO. SERIAL NO. PLATFORM SIZE CONDITION OF DECK APPROACHES
AKE DILATOR
MODEL NO.
SERIAL N0.
SCALE CAPACITY CLC SEC
415*11
SR at ZERO LOAD
SR at MAX. LOAD
# OF WEIGH MASTERS
SCALE AND COMPUTER INTERFACED
'YES 11 NO
—A
.V -" 14
(
TYPE OF BUSINESS
DATE OF LAST INSPECTION +-+
"TEST RESULTS"
t7._ tI
ZERO BALANCE
AS FOUND
0
6
LOAD
POSITION
TEST
WEIGHTS
SCALE
INDICATION
:ERROR
LOAD
POSITION
TEST
WEIGHTS
SCALE
INDICATION
ERROR
all
4 f
S
ws` 80
ZERO BALANCE
;,+r
0
"STRAIN LOAD TEST"
ACTION TAKEN: ❑ APPROVED REJECTED ❑ RELEASED ❑ LAW GIVEN ❑ REGULATION GIVEN
REMARKS: '