Forms • Dickinson County • CivicEngage

Employee Name*

Return Phone Number
Example (2633120)*

Date & Time Problem was Noticed*

Unit Number or Department & Vehicle*

Mileage and/or Hours*

Basic Maintenance

Oil Change

Engine

	Check for Oil, Water and Fuel Leaks
	Service Engine Light is on
	Knocks

	Misses
	Starts Hard
	Overheating

Clutch

Check for Slipping or Grabbing

Check Adjustment

Tires

Repair Tire

Check Wheels and Lugs

Steering

	Looseness
	Shimmy

Steers Hard

Springs/Suspension

Broken

Electrical

	Check Trailer Light Cord
	Lights: Head, Tail, Stop, Clearance

Warning Beacon

Hydraulic System

Operation

Instrumet Panel

	Oil Pressure Gauge
	Ammeter
	Horn

	Windshield Wipers
	Speedometer

Rear Axle

Noisy

Grease leaks

Transmission

	Noisy
	Hard Shifting

Leaks

Emergency Equipment

	Fire Extinguisher
	First Aid Kit

Three Reflective Triangles

Brakes

	Check Trailer Connection
	Parking Brakes

	Service Brakes
	Check for air or hydraulic leaks

Miscellaneous

	Drive Line
	5th Wheel safety chain, pintle hook

Door glass, windshield, mirrors

Other

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