FACTORY INSPECTION REPORT

(Refer to DQD 320 Series)

Factory ID: 4500803 Trip Number: ONT050Q2 Page 1 of 2
Factory Contract: 150771 PO Number: N/A
Master Contract: 150770 Arrival: 13:14 Depart: 14:25
Legacy Number(s): 094076 Date: Aug 15, 2018

Summary Inspection Code(s): K

Submittor D.L. Custom, A Div. of 304260 Ontario Limited Factory: D.L. Custom, A Div. of 304260 Ontario Limited
4500803 7250 Victoria Park Ave, Unit B 7250 Victoria Park Ave, Unit B

Markham Markham
Ontario L3R 2M5 Ontario L3R 2M5
Canada Canada

Have any complaints been received since last inspection? Have you initiated any
safety related recall activities or contacted CPSC, Health Canada, FDA, ESA, Régie
Is a system in place for recording customer complaints? Yes du bâtiment or other regulatory body about safety related product incidents or No
defects?

Traceability of Incoming Materials/Procedures Reviewed & Found Acceptable? Yes

Observations:
Factory: (Observations): Conducted inspection with Alex Hull
Factory Contact Questionnaire was reviewed - no changes to note at this time.
Incoming materials are verified and there have been no changes to the process since last inspection.
No safety related issues have been reported to the manufacturer from CSA product shipped from this location that involve
personal injury or property damage since the last inspection. Manufacturer is aware to report to CSA any issues that involve
these types of incidents immediately.
There was no follow up from the previous visit to address.
Toured production area, stock areas, testing area, shipping/receiving and found the following.

5842-81 (Product): Cord connected multiple receptacle extension boxes (Model): TPS-12 (Ratings): 125Vac 15amps (SN):
N/A (Reports Referenced): 1142478/1777916 (Stds Referenced): Csa C22.2 21-95, 42-99, Informs Cord set No. 7A. ANSI/UL
817 11th Ed. (Marking Deviations): N/A (Observations): Note: Selection of annual Conformity Testing samples of the
extension boxes is not presently applicable to this CSA Class No. 5842 81 Listing, as the product incorporates CSA Certified
and UL Recognized receptacles in their extension boxes.
Note: Selection of samples for annual Conformity Testing is not presently required, due to the Listed power bars not
incorporating MOV protectors.
Construction as per report

Factory Tests Applied:

Class S/N Cal Due % of Funct. Accept
No. Type of test Manufacturer Model or ID Date Value Prod Check -able
5842-81 Polarity/Gndg/ Greenlee GT-10 GFI N/A N/A N/A N/A N/A
Continuity

Immediate Changes:
Factory: (Inspection Codes:) K (Immediate Changes:) None

5842-81: (Model:) TPS-12 (Inspection Codes:) K (Immediate Changes:) None

As the facility representative, the undersigned, hereby agrees that all production subsequent to the time of the inspection will incorporate required changes.
Name: Alex Hull Name: Kirk Davy CSA Office: TORONTO
(Facility Representative) (CSA Representative) Employee No: 3359
(905-475-0275, Email: alexhull@dlcustom.com) (Email: kirk.davy@csagroup.org)

Signature: I have read and understand this report as written.

Listed items not complying with CSA requirements are not eligible to bear the CSA Mark - MISUSE OF THE CSA MARK MAY RESULT IN CANCELLATION OF EXISTING AGREEMENT
DQD 513 Rev. 2017-03-24 © The CSA Group Management Corporation. All rights reserved.
 FACTORY INSPECTION REPORT
(Refer to DQD 320 Series)
Factory ID: 4500803 Trip Number: ONT050Q2 Page 2 of 2
Factory Contract: 150771 PO Number: N/A
Master Contract: 150770 Arrival: 13:14 Depart: 14:25
Legacy Number(s): 094076 Date: Aug 15, 2018

Summary Inspection Code(s): K

Samples selected?
Is the mfg aware

accordance with
compliance with

effective dates?

Mark removed?

corrected on all
complied with?
and material in
Is construction

Was the CSA

Were defects
requirements

Is marking in

How Applied

Reviewed &
Component

Time Spent
Inspection

Resolved?
of the new

Required?
Follow Up
Per Class
samples?
report/s?

(hrs:min)
Are new

Retest/
report?

Follow
Codes

Class

Up
No.
Factory K - - - - - - - - 00:30 - No
5842-81 K Yes N/A N/A Yes PS Adhesive Label N/A N/A N/A 00:50 - No
The manufacturer agrees to apply the following markings:
• Products shall be marked with the markings specified by the particular product standard.
• Products certified for Canada shall have all Caution and Warning markings in both English and French.
Additional bilingual markings not covered by the product standard(s) may be required by the Authorities Having Jurisdiction. It is the responsibility of the manufacturer to provide and
apply these additional markings, where applicable, in accordance with the requirements of those authorities.

As the facility representative, the undersigned, hereby agrees that all production subsequent to the time of the inspection will incorporate required changes.
Name: Alex Hull Name: Kirk Davy CSA Office: TORONTO
(Facility Representative) (CSA Representative) Employee No: 3359
(905-475-0275, Email: alexhull@dlcustom.com) (Email: kirk.davy@csagroup.org)

Signature: I have read and understand this report as written.

Listed items not complying with CSA requirements are not eligible to bear the CSA Mark - MISUSE OF THE CSA MARK MAY RESULT IN CANCELLATION OF EXISTING AGREEMENT
DQD 513 Rev. 2017-03-24 © The CSA Group Management Corporation. All rights reserved.