JC International Limited

RC. 413243
Port Harcourt Office: Plot 5 JC Street, Off Peter Odili Road, P.O. Box 6427 Trans Amadi Port Harcourt, Rivers State. Tel: +234-84-489909 Lagos Office: 56A Bourdillon Road, P.O. Box 52224 Ikoyi. Tel: +234-1-842-5813 E-mail: service@jcinternationalng.com Website: www.jcinternationalng.com

VERTICAL MAST FORKLIFT INSPECTION REPORT

ID. No: E0583 Manufacturer: MITSUBISHI Serial No: A4BC240403 Model: SWL: 5000LBS Date Manufactured: 2011 Legends: S U Location: PACIFIC SCIROCCO Inspector: FREDERICK MINA Satisfactory Unsatisfactory Not Applicable

FBC 25N

CATERPILLAR HOUSTON TEXAS USA Owner: PACIFIC DRILLING

Date of Inspection: 31/10/2013

Place of Test: SACK STORE Date of Last Test: Not seen Date of Next Inspection: 30/04/2014
STATUS: OK

N/A

SERIES: Chasis No: Description: VERTICAL MAST FORKLIFT TRUCK Specification: ASME B 56.6

CHASIS Steering Axle Hydraulic System Wheels Tyres Brakes Light Indicator Gauges Suspension Good Good Good Good Good Good Good Good Good

FORKS Forks Blade Good

NDE
MPI OK

Good Tilt Cylinder Hydraulic System Good Good Fork Heels

Inspectors Name/Qualification

Signature/Date: 31/10/2013

LOAD TEST

FREDERICK MINA
FMLP, LEEA, NDT LEVEL II MT, PT, UT, VT Lifting Equipment Insp.

YES
Page 1 of 5

JC International Limited
RC. 413243

CHECKLIST FOR FORKLIFT INSPECTION

Name & Address of the Owner Pacific Drilling Name & Address of the Manufacturer: MITSUBISHI CATERPILLAR HOUSTON TEXAS, USA Type VERTICAL MAST FORKLIFT TRUCK Location: PACIFIC SCIROCCO Serial No: Codification No:
A4BC240403

Date of thorough examination 31/10/2013 Date of last thorough Inspection

Relevant Standard ASME B 56.6 Capacity: 5000lbs Model No: FBC 25N
Relief Valve Adjustment

Not seen Survey Requested By OLUMIDE ADIGUN

Date of last load test and Insp.

Not seen Chasis No.

E0583

Test Load Applied 5500lbs Date of last Proof load Test Not Seen
Tilt Cylinder Creep in 5 minutes NONE

Date of next Thorough Insp.

Good Validity of this certificate 12 MONTHS

Comments:

Comments noted and alterations or repairs required before Forklift are put into service (if none enter NONE)

Page 2 of 5

JC International Limited
RC. 413243

SECTION

NEEDED CORRECTIONS (if any) DEFECTS NOTED

General: Wheels Tyres Mast and Fork-carrier Load Chain Roll-over cage Forks Horn and Safety Devices Hydraulic System Electrical System Engine Compartment Charging System Cooling System Steering Operational Controls Gauges in Cab Fire Extinguisher Maintenance
Inspectors Name/Qualification

Good 0577.3hr Good Good Good Good Good Good Good Good Good Good Good N/A Good Good Good Good Good
Signature/Date

FREDERICK MINA
FMLP, LEEA, FID, NDT LEVEL II MT, PT, UT, VT Lifting Equipment Insp.

Page 3 of 5

JC International Limited
RC. 413243

Section 1
1.1 a) b) c) d) e) f) g) h) i) j) k) l) m) n) o) p) q) r) s) t) u) v) w) x) y) z)

Operators Cab

NA

Operators Cab Condition: Access / Handholds / Steps Non-slip surfaces House keeping Door(s) Glass Window Wiper Heater/Air Conditioner Wiring Emergency Stop Mirrors Seat/Seats Belts Instruments and gauges Roof access Load Capacity Chart Operators Manual Warning Decals Power Line Warning Decal Hand Signal Chart Lights Trafigator Reverse Light Revolving light Break Light Lift Cylinder Parking Brake/Hand Brake Pedals
Rear head lamp not functioning.

Replace

Page 4 of 5

JC International Limited
RC. 413243
Port Harcourt Office: Plot 5 JC Street, Off Peter Odili Road, P.O. Box 6427 Trans Amadi Port Harcourt, Rivers State. Tel: +234-84-489909 Lagos Office: 56A Bourdillon Road, P.O. Box 52224 Ikoyi. Tel: +234-1-842-5813 E-mail: service@jcinternationalng.com Website: www.jcinternationalng.com

TEST CERTIFICATE
STATUTORY INSTRUMENTS 1998 NO. 2307 The Lifting Operations and Lifting Equipment Regulations 1998 STATUTORY INSTRUMENTS 1992 NO. 3073 The Supply of Machinery (Safety) Regulations 1992 STATUTORY INSTRUMENTS 1998 NO. 2306 The Provision and use of Work Equipment Regulations 1998

Factories Act CAP. 126 L.F.N 1990 Equipment Description: Client: Inspection Location: Forklift Type: Forklift Manufacture: Model Number: Serial Number: SWL: Proof Load Applied: Certificate Number: Inspection Date: Next Date of Examination: VERTICAL MAST FORKLIFT
PACIFIC DRILLING

PACIFIC SCIROCCO VERTICAL MAST CATERPILLAR FBC 25N A4BC240403 5000LBS 5500LBS 25925 31/10/2013 30/04/2014

This is to certify that I did thorough Visual Examination and Test on the Forklift in accordance with ASME B 56.6 and all statutory requirements as above. The records of examination are true without prejudice for the purpose it was designed for. Fit for use.
Inspectors Name/Qualification Signature/Date

FREDERICK MINA
FMLP, LEEA, NDT LEVEL II MT, PT, UT Lifting Equipment Insp. 31 OCTOBER, 2013
ST

JC International Limited
Port Harcourt Office: Plot 5 JC Street, Off Peter Odili Road, P.O. Box 6427 Trans Amadi Port Harcourt, Rivers State. Tel: +234-84-489909 Lagos Office: 56A Bourdillon Road, P.O. Box 52224 Ikoyi. Tel: +234-1-842-5813 E-mail: service@jcinternationalng.com Website: www.jcinternationalng.com

RC. 413243

VERTICAL MAST FORKLIFT INSPECTION REPORT

ID. No: Manufacturer: MITSUBISHI Serial No: A4BC240394 Model: SWL: 5000LBS Date Manufactured: 2011 Legends: S U Location: PACIFIC SCIROCCO Inspector: FREDERICK MINA Satisfactory Unsatisfactory Not Applicable

FBC 25N

CATERPILLAR HOUSTON TEXAS USA Owner: PACIFIC DRILLING

Date of Inspection: 02/11/2013

Place of Test: HOLD STORE Date of Last Test: Not seen Date of Next Inspection: 01/05/2014
STATUS: OK

N/A

SERIES: Chasis No: Description: VERTICAL MAST FORKLIFT TRUCK Specification: ASME B 56.6

CHASIS FORKS Steering Axle Hydraulic System Wheels Tyres Brakes Light Indicator Gauges Suspension Good Good Good Good Good Good Good Good Good Forks Blade Good NDE
MPI OK

Good Tilt Cylinder Hydraulic System Good Good Fork Heels

Inspectors Name/Qualification

Signature/Date: 02/11/2013

LOAD TEST

FREDERICK MINA
FMLP, FID, NDT LEVEL II MT, PT, UT, VT Lifting Equipment Insp.

YES
Page 1 of 5

JC International Limited
RC. 413243

CHECKLIST FOR FORKLIFT INSPECTION

Name & Address of the Owner Pacific Drilling Name & Address of the Manufacturer: MITSUBISHI CATERPILLAR HOUSTON TEXAS, USA Type D767122 Location: PACIFIC SCIROCCO Serial No: Codification No:
A4BC240394

Date of thorough examination 02/11/2013 Date of last thorough Inspection Not seen Relevant Standard ASME B 56.6 Capacity: 5000lbs Model No: FBC 25N
Relief Valve Adjustment

Survey Requested By OLUMIDE ADIGUN

Date of last load test and Insp.

Not seen Chasis No.

E0583

Test Load Applied 5500lbs Date of last Proof load Test Not Seen
Tilt Cylinder Creep in 5 minutes NONE

Date of next Thorough Insp.

Good Validity of this certificate 12 MONTHS

Comments:

Comments noted and alterations or repairs required before Forklift are put into service (if none enter NONE)

Page 2 of 5

JC International Limited
RC. 413243

SECTION

NEEDED CORRECTIONS (if any) DEFECTS NOTED

General: Wheels Tyres Mast and Fork-carrier Load Chain Roll-over cage Forks Horn and Safety Devices Hydraulic System Electrical System Engine Compartment Charging Unit Cooling System Steering Operational Controls Gauges in Cab Fire Extinguisher Maintenance
Inspectors Name/Qualification

Good 0387.5hr Good Good Good Good Good Good Good Good Good Good Good Good Good Good Good Good Good
Signature/Date

FREDERICK MINA
FMLP, LEEA, FID, NDT LEVEL II MT, PT, UT, VT Lifting Equipment Insp.

Page 3 of 5

JC International Limited
RC. 413243

Section 1
1.1 a) b) c) d) e) f) g) h) i) j) k) l) m) n) o) p) q) r) s) t) u) v) w) x) y) z)

Operators Cab

NA

Operators Cab Condition: Access / Handholds / Steps Non-slip surfaces House keeping Door(s) Glass Window Wiper Heater/Air Conditioner Wiring Emergency Stop Mirrors Seat/Seats Belts Instruments and gauges Roof access Load Capacity Chart Operators Manual Warning Decals Power Line Warning Decal Hand Signal Chart Lights Trafigator Reverse Light Revolving light Break Light Lift Cylinder Hand Brake Pedals

Rear Head lamp not functioning. Replace rear hand lamp

Page 4 of 5

JC International Limited
RC. 413243
Port Harcourt Office: Plot 5 JC Street, Off Peter Odili Road, P.O. Box 6427 Trans Amadi Port Harcourt, Rivers State. Tel: +234-84-489909 Lagos Office: 56A Bourdillon Road, P.O. Box 52224 Ikoyi. Tel: +234-1-842-5813 E-mail: service@jcinternationalng.com Website: www.jcinternationalng.com

TEST CERTIFICATE
STATUTORY INSTRUMENTS 1998 NO. 2307 The Lifting Operations and Lifting Equipment Regulations 1998 STATUTORY INSTRUMENTS 1992 NO. 3073 The Supply of Machinery (Safety) Regulations 1992 STATUTORY INSTRUMENTS 1998 NO. 2306 The Provision and use of Work Equipment Regulations 1998

Factories Act CAP. 126 L.F.N 1990 Equipment Description: Client: Inspection Location: Forklift Type: Forklift Manufacture: Model Number: Serial Number: SWL: Proof Load Applied: Certificate Number: Inspection Date: Next Date of Examination: VERTICAL MAST FORKLIFT
PACIFIC DRILLING

PACIFIC SCIROCCO VERTICAL MAST CATERPILLAR FBC25N A4BC240394 5000LBS 5500LBS 25924 02/11/2013 01/05/2014

This is to certify that I did thorough Visual Examination and Test on the Forklift in accordance with ASME B 56.6 and all statutory requirements as above. The records of examination are true without prejudice for the purpose it was designed for. Fit for use.
Inspectors Name/Qualification Signature/Date

FREDERICK MINA
FMLP, LEEA, NDT LEVEL II MT, PT, UT Lifting Equipment Insp. 02
ND

NOVEMBER, 2013