Maintenance

Inspection Form
NAME ____________________________________ MEMBER # __________________________________ DATE _________________________
YEAR _________________ MAKE __________________________ MODEL _________________________ MILEAGE _______________________
VISIBILITY NOTES/RECOMMENDATIONS
Windshield CRACKED PITTED BULLSEYE
Wiper Blades L R REAR
Mirrors L R INSIDE
LIGHTS
Headlights L R LO HI
Park/Tail Lights LF RF LR RR
Brake Lights L R CENTER
Backup Lights L R
Turn Signals LF RF LR RR
Side Markers LF RF LR RR
License Plate Lights
WARNING SYSTEMS
Horn
Emergency Flashers LF RF LR RR
LUBRICANT/FLUIDS
Engine Oil LEVEL COND LEAKS
Transmission Fluid LEVEL COND LEAKS
Power Steering Fluid LEVEL COND LEAKS
Brake Fluid LEVEL COND LEAKS
Clutch Fluid LEVEL COND LEAKS
Washer Fluid LEVEL COND LEAKS
Engine Coolant LEVEL COND LEAKS ANTIFREEZE PROTECTION TEST RESULT: F/ C
BATTERY
Carrier/Hold-Down MISSING LOOSE CORRODED
Cables/Terminals MISSING LOOSE CORRODED
Charge Indicator GREEN DARK CLEAR/YELLOW BATTERY TEST RESULT:
BELTS
Serpentine WORN IDLER TENSIONER
Alternator WORN LOOSE PULLEY
Air Conditioning WORN LOOSE PULLEY
Power Steering WORN LOOSE PULLEY
Water Pump WORN LOOSE LEAKS
Air Pump WORN LOOSE PULLEY
HOSES
Radiator UPPER LOWER LEAKS
Heater INLET OUTLET LEAKS
Bypass/Other COND LEAKS
Power Steering LO-PRESS HI-PRESS LEAKS
Transmission Cooler INLET OUTLET LEAKS
Vacuum COND LEAKS
Fuel (Underhood Only) COND LEAKS
OTHER UNDERHOOD
Air Filter DIRTY MISSING
Radiator Cooling Fan(s) MECHANICAL ELECTRIC
TIRES
Pressure (psi) LF RF LR RR SPARE
Tread (x/32) LF RF LR RR SPARE MINIMUM SAFE DEPTH 3/32

EVALUATION KEY: = SATISFACTORY = NEEDS SERVICE SOON = NEEDS SERVICE NOW

ACKNOWLEDGEMENT
I have reviewed this Maintenance Inspection Form and understand that it reflects the condition of my vehicle at the time of the inspection only. I recognize that this is a basic visual inspection, not a compre-
hensive vehicle evaluation, and additional problems may exist in systems and/or components that were not checked as part of this inspection. I accept that this inspection is made without warranty of
any kind, either expressed or implied, or arising by operation of law. I acknowledge that no action has been taken to correct any condition(s) reported, and that the safe operation and maintenance of
the vehicle following this inspection is my sole responsibility. I also agree that the results recorded above may be used in assembling statistics regarding vehicle maintenance, and that copies of this report
may be provided to the program sponsors upon request.

MOTORIST FACILITY
SIGNATURE NAME / # DATE
REV. 3/08 Stock # 4123
SHOP COPY