*** SAMPLE DOCUMENT - FICTIONAL - NOT A REAL CERTIFICATE ***

PERIODIC INSPECTION REPORT
Mobile elevating work platform

Report No.:            SAMPLE-INS-001

Equipment:             Electric scissor lift
Model:                 SAMPLE-10E
Serial No.:            SAMPLE-0042
Year of manufacture:   2023
Working height:        10 m
Rated load:            230 kg

Owner:                 Rental company (sample)
Inspection body:       Inspection body X (sample)

Date of inspection:    12.05.2026
Result:                PASSED - safe for use
Next inspection due:   12.05.2027

Checks performed:
- structure and scissor mechanism
- hydraulic system
- guardrails and entry gate
- emergency stop and emergency lowering
- electrical system and battery
- load test

Remarks: none.

Inspector: (signature)                         SAMPLE