FRA F 6180.4EZ Safety Sample Car Inspection Report

OMB No. 2130-0565
Public reporting burden for this information collection is estimated to average 70 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and
and maintaining the data needed, and completing and reviewing the collection of information.  According to the Paperwork Reduction Act of 1995, a federal agency may not conduct or sponsor and a person is
not required to respond to, nor shall a person be subject to a penalty for failure to comply with, a collection of information unless it displays a currently valid OMB control number. The valid OMB control number
for this information collection is 2130-0565.  All responses to this collection of information are mandatory.  Send comments regarding this burden estimate or any other aspect of this collection, including
suggestions for reducing this burden to: Information Collection Officer, Federal Railroad Administration, 1200 New Jersey Ave., S.E., Washington D.C. 20590.

ADDRESS:

FRA
CONTROL NUMBER

SAMPLE CAR
INSPECTION
REQUEST INFORMATION:
Contact Name:
Title:
Business Phone:
E-Mail Address:
Build Location Name:

Date:
Job or Order No.:
Proposed Car Type:
Type of Car:
Qty. of Cars:
Reporting Marks:
Series Numbers:

Build Location Address:
Sample Car Inspection Request:

Yes:
Yes:

No:
No:
Request Sent To:
No:

Stamped Serial Numbers:

Customer:
Inspection Request:
Site Rep. Name:

Review DWG Request:
FRA Contacts
Director Office of Safety:

Yes:

FRA SA/HQTRS Specialist:

Yes:

No:

Site Rep. Title:

FRA Region Specialist:

Yes:

No:

Site Rep. Phone No.

FRA MP&E Staff Dir:

Yes:

Production Start Date:
FRA SCI Request Date:
Base Car:
If "YES", Base Control No:

Yes:

CFR Part or 231.18 Nearest Car:

Yes:

No:

No:
CAR CONSTRUCTION INFORMATION - (Note: applies only to safety appliances)
Production End Date:
Temp. Reporting Marks: Yes:
No:
No:
AAR S-2044 Standard:
APTA Standard:

Actual CFR:
Additional Information:

Deviations, if any:

Supplimental information provided.
Yes:
No:
Justification for Relief:

Documents Submitted
Safety Appliance Dwg.: Yes:

CAR CONSTRUCTION DETAILS
Number
Dwgs.
Rev.

Comments (If Document Not Complete)

No:

Brake Assy Dwg.:

Yes:

No:

Reflectorization Dwg.:

Yes:

No:

Specialty List:

Yes:

No:

Brake Force Test:

Yes:

No:

Curve Test:

Yes:

No:

Brake Dimension Dwg.:

Yes:

No:
DO NOT WRITE BELOW THIS LINE

FRA REGIONAL OFFICE OF SAFETY ASSURANCE & COMPLIANCE REVIEW, FIELD INSPECTION REVIEW AND SIGN OFF
Inspection Date:

Grid Sign Off

Regional Office
Signature:

MP&E Inspector:

DWG Review Date:
Insp. Report to Builder:

Yes:

No:

Date:

Exception to Design:

Yes:

No:

Regional Specialist:

Exception w/comments

Yes:

No:

Date:

F6180.96 Inspection Report:

Yes:

No:

Regional Administrator:

F6180.4 SCI Report:

Yes:

No:

Date:

Photographs (Six) Minimum:

Yes:

No:

Photo Qty:

Deviation Photographs:

Yes:

No:

Photo Qty:

Signature
Signature

Regional Comments:

HEADQUARTERS REVIEW AND SIGN OFF
Headquarters, Accepted:

Yes:

No:

Headquarters Comments:

Safety Appliance Spec.:

FRA Takes No Exception To This Equipment At This Time
Signature:

Date:
MP&E Staff Director:

Signature

Date:
FRA response should in no way be construed as a certification or
approval that the equipment complies with all Federal requirements.
OMB No.F 6180.4 EZ (3-11) (Office of Railroad Safety)

Office of Safety Director:

Signature

Date:
Response Sent by:

Date: