Form FRA Form No. 5 FRA Form No. 5 Locomotive Service Day Record

OMB No. 2130-0505

Form No. 5

Locomotive Service Day Record

Locomotive Initial and No. ___________________________ owned by _____________________________________ and operated
by _________________________ was placed in service following a 1472 Service Day Inspection on (start date) ___________________.
This locomotive shall not be operated after (date) ___________, or it shall not be operated after it has accumulated 1472 service days from
the above start date, whichever comes first, at which time it shall be due for a 1472 Service Day Inspection.
Year

Serv. days since last insp.
Annual Date
Serv. days since last insp.
31 Service Day Date
Serv. days since last insp.
31 Service Day Date
Serv. days since last insp.
92 Service Day Date
Serv. days since last insp.
31 Service Day Date
Serv. days since last insp.
31 Service Day Date
Serv. days since last insp.
92 Service Day Date
Serv. days since last insp.
31 Service Day Date
Serv. days since last insp.
31 Service Day Date
Serv. days since last insp.
92 Service Day Date
Serv. days since last insp.
31 Service Day Date
Serv. days since last insp.
31 Service Day Date
Serv. days since last insp.
Annual Date
TOTAL

A copy of this record shall be filed with the Regional Administrator after 31 December and prior to 31 January of each year.

Signed ____________________________ Officer in Charge
Public reporting burden for this information collection is estimated to average 15 minutes per response, including the time for reviewing instructions, searching existing
data sources, gathering 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 2130-0505. 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.

FRA Form No. 5

(01/09)

Expires 08/31/2018