Vehicle Mechanical Inspection Report for Transportation Subject to Department of Labor Safety Standards U.S. Department of Labor Employment Standards Administration Wage and Hour Division Name of Carrier OMB No. 1215-0036 Expires: 08-31-2010 State Address ZIP Code Important The Migrant and Seasonal Agricultural Worker Protection Act requires that farm labor contractors subject to this law who transport any migrant and seasonal agricultural workers for agricultural employment obtain from the U.S. Department of Labor a certificate of registration. Applicants for a certificate of registration must produce evidence that the vehicles they use for this purpose meet Department of Labor requirements. Provided below is a list of major items which should be chocked. On the reverse side of this form is a brief summary of the Department of Labor standards for each of these items. A check ( ) should be placed adjacent to each item which meets these minimum standards. In those instances where an item does not meet these standards, necessary repairs must be completed before the transportation of migrant and seasonal agricultural workers will be authorized. This form must be properly completed and signed, certifying that the vehicle meets Department of Labor requirements. This form (WH-514a) is to be used for the inspection of any passenger car or station wagon regardless of the distance traveled and for other vehicles used to transport migrant and seasonal agricultural workers (except day-haul operations) for distances of seventy five (75) miles or less. vehicles used in day-haul operations and those used to transport workers for more than 75 miles are subject to Department of Transportation standards. Form WH-514 must be used for inspection of such vehicles. If the farm labor contractor possesses a valid current State vehicle safety inspection sticker from the jurisdiction in which the vehicle is registered, the items listed below need not be checked. However, in the Remarks section, the farm labor contractor must identify the State where the inspection was performed, list the appropriate State vehicle safety inspection number and license tag number and then sign and date the form. Vehicle: Serial or Motor No. Tractor Truck No. of Seats Semitrailer Full Trailer Registration No. Lighting Devices (1) Headlights (2) Stop Lights (3) Tail Lights (4) Back-up Lights (5) Turn Signals Bus Passenger Car Make State Brakes (6) Service (Foot) (7) Parking Brake Emergency Equipment (12) Hazard Warning Lights Van Station Wagon Passenger Compartment (8) Windshield/Windows (9) Ventilation (10) Seats (11) Door-Handles/Latches Parts and Accessory (17) Windshield Wipers (18) Rear Vision Mirrors (19) Fuel System (20) Exhaust System (13) Tires (14) Side Mirrors (15) Steering (16) Horn Remarks: Name of Shop (Garage) Name of Person Making Inspection Address where Inspection is Performed Title Telephone Number Date of Inspection Public Burden Statement Public reporting burden for this collection of information is estimated to average 5 minutes per response, including time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to the Administrator, U.S. Department of Labor, Wage and Hour Division, Room S-3502, 200 Constitution Avenue, N.W., Washington, D.C. 2021 0. Persons are not required to respond to this collection of information unless it displays a currently valid OMB control number. DO NOT SEND THE COMPLETED FORM TO THIS OFFICE Form WH-514a Rev. Oct 1998 American LegalNet, Inc. www.FormsWorkflow.com MSPA 29 CFR 500.104 DOL VEHICLE SAFETY STANDARDS External Lights: Operable headlights, tail lights, stop lights and, if so equipped, back-up lights, turn signals, and hazard warning lights. Brakes: Operable and free of leaks. Tires: No cracks/defects in sidewall and tread depth at least 2/32 inch. Steering: Steering wheel and linkage properly adjusted and maintained. Horn: Operable air or electric horn. Mirrors: Must provide full vision to the sides and rear. Windshield/ Windshield Wipers: Windshields must have no cracks which obscure vision and no opaque obstructions. Windshield wipers must be operable in all weather conditions. Fuel System: Fuel lines and tank must be free of leaks and filling opening securely covered by a cap. Exhaust System: Must discharge carbon monoxide away from passenger com­ partment and be free of leaks. Ventilation: Windows must be operable to allow fresh air to occupants. Safe Loading: Loading must not exceed gross vehicle weight rating. Seating: Seat required for each passenger except that seating not re­ quired for vehicles used on trips of less than 10 miles which begin and end on the farm and transportation is primarily on farm roads. Handles & Latches: Door handles and latches operable to allow exiting for occupants. Passenger Compartment: Floor and sides of any part of the vehicle to be occupied by passenger must be free of openings or rusted areas which are likely to result in injury to passengers. 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