C.E. Holt Monthly Truck Report Form
Date
-
Month
-
Day
Year
Date
Name
*
Current Odometer Reading
*
TRUCK #
*
I have confirmed the truck # and odometer reading entered above are correct
*
True
False
Vehicle Brakes
*
Please Select
New, Replaced in last 3 months
Good, Working without issues
Fair, working but haven't been replaced in some time
Poor - having issues
Tires
*
Please Select
New, Replaced in last 3 months
Good, Working with solid tread left
Fair - starting to have some wear but working fine
Poor - going bald in areas, poor tread depth
Vehicle Maintenance
*
Good - Working as if new, no issues
Poor - Issues affecting working, need to be replaced
Engine Oil Level
Trans Fluid Level
Head Lights
Brake Lights
Wiper Blades
Wiper Fluid
Tire Pressure
Battery
Hoses
Spare Tire
Tie Down Straps
Check Engine Light
Registration
Proof of Insurance
My Vehicle has a Fire Extinguisher
*
True
False
Year Stamped on Vehicle Extinguisher
*
Month Stamped on Vehicle Extinguisher
*
January
February
March
April
May
June
July
August
September
October
November
December
My Torch has a Fire Extinguisher
*
True
False
Year Stamped on Torch Extinguisher
*
Month Stamped on Torch Extinguisher
*
January
February
March
April
May
June
July
August
September
October
November
December
SAFETY/OSHA Compliance
*
True
Have Issues I need to bring to someone's attention
N/A Not Applicable to my Truck
SDS Book on Truck (formerly MSDS)
Accident Reporting Kit on Truck?
Compressed Gas Cylinders Secured in Upright Position?
Work Lamps Grounded and Covered?
First Aid Kit on truck?
Do Not Need Any First Aid items?
Extension Cords in Good Condition? (Not frayed or ground plug broken)
Ladders Marked CEH and Labels Readable?
Ladders Are Not Cracked?
Anything else????
Do you have any urgent request on this report?
*
No Urgent Request
Somewhat Urgent
Extremely Urgent
Do you want a confirmation email?
*
Yes
No
Email
*
example@example.com
My First Aid Kit Has Expired
*
True
False
Submit
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