Street Address License#: State: USDOT#: Phone#: (123) CoDriver: MC/MX#: Fax#: License#: State:

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1 LOGO U.S. DEPARTMENT OF TRANSPORTATION DRIVER/VEHICLE EXAMINATION REPORT FEDERAL MOTOR CARRIER SAFETY ADMINISTRATION Report Number: USXXXXXXXXXX Illinois Field Office Inspection Date: 3250 Executive Park Drive Start Time: HH:MM AMEnd Time: HH:MM Springfield, IL ph. (217) Insp. Level: 5-Terminal, No HM Insp. Company name Driver: Street Address License#: State: City, State, Postal Code Date of Birth: USDOT#: Phone#: (123) CoDriver: MC/MX#: Fax#: License#: State: State#: Date of Birth: Location: street address, city, state MilePost: Shipper: Highway: Origin: Bill of Lading: County: county, state Destination: Cargo: VEHICLE IDENTIFICATION Unit Type Make Year State License# Company# Vin# GVWR CVSA# OOS# BRAKE ADJUSTMENTS Axle # Right Left Chamber VIOLATIONS Section Code Type Unit OOS Citation# Verify Crash Violations Discovered HazMat: Placard: Cargo Tank: Special Checks: NOTE TO DRIVER: This report must be furnished to the motor carrier whose name appears at the top of this report [49 CFR 396.9(d)(1)] NOTE TO MOTOR CARRIERS: Pursuant to authority contained in Title 49, Code of Federal Regulations, Section 396.9(d)(3), within 15 days of the inspection sign below certifying all violations noted on this report have been corrected. Return the completed form to the address indicated on the upper left corner of the form, AND retain a copy at the principal place of business or where the vehicle is housed for 12 months from the date of inspection. Failure to return this report with the required certification can result in penalties up to $550 per day for each day the violation continues, up to a total of $5,500. Signature of Motor Carrier X: Title: Date: Report Prepared By: Badge #: Copy Received By: John Doe XX1234 X X

2 US DOT # Legal: company name Operating (DBA): company name MC/MX #: Federal Tax ID: Review Type: Scope: Location of Review/Audit: Company name & location Territory: Operation Types Interstate Intrastate Carrier: Shipper: Cargo Tank: Company Physical Address: Street address City, state, postal code Business: type of business Gross Revenue: dollar amount Contact Name: contact name Phone Numbers: (1) (2) Fax: Address: address of contact Company Mailing Address: Street address City, state, postal code Report Summary Report # of Pages for year ending: Part A General Part B Questions & s Part B Proposed Result Part B Recommendations Review/audit Receipt Page Total Pages Disclaimer: By signing below, I acknowledge that I have received a copy of this review/audit and agree with the total number of pages indicated (above) for reach document. My signature does not imply agreement with the findings of the review/audit, however they have been discussed in detail with me. QUESTIONS regarding this report or the Federal Motor Carrier Safety or Hazardous Materials rules may be addressed to the Office of Motor Carriers at: FMCSA Hotline Phone: (703) This SAFETY AUDIT will be used to assess your safety compliance Person(s) Interviewed Name: Title: Name: Title: Reported By: Title: Code: Date: Received By: Title

3 US DOT # Legal: company name Operating (DBA): company name MC/MX #: Federal Tax ID: Review Type: Scope: Location of Review/Audit: Company name & location Territory: Operation Types Interstate Intrastate Business: type of business Carrier: Shipper: Gross Revenue: dollar amount for year ending: Cargo Tank: Company Physical Address: Street address City, state, postal code Contact Name: contact name Phone Numbers: (1) (2) Fax: Address: address of contact Company Mailing Address: Street address City, state, postal code Carrier Classification classification type Cargo Classification Other: cargo type Does carrier transport placardable quantities of HM? Yes or No Is an HM Permit Required? Yes or No Driver Information Inter Intra Average trip leased drivers/month: # < 100 Miles: # # Total Drivers: # >=100 Miles: # # CDL Drivers: # Equipment Owned Term Leased Trip Leased Owned Term Leased Trip Leased Truck # # # # # # Power units used in the U.S.: # Percentage of time used in the U.S.: #

4 Part A QUESTIONS regarding this report or the Federal Motor Carrier Safety or Hazardous Materials rules may be addressed to the Office of Motor Carriers at: FMCSA Hotline Phone: (703) Person(s) Interviewed Name: Name: This SAFETY AUDIT will be used to assess your safety compliance Title: Title:

5 Part B Questions and s An asterisk (*) beside an answer indicates an area of non-compliance by the motor carrier, and negatively affects the results of the audit. Question General #1 Section #387.7(a) Acute Does the carrier have the required minimum level of financial responsibility in effect? Question General #2 Section #387.7(d) Acute Does the carrier have required proof of financial responsibility? Question General #3 - Section #390.15(b)(1) Can the carrier provide a complete accident register of recordable accidents? Question General #4 - Section #390.15(b)(2) Critical Does the carrier have copies of all accident reports required by States or other government entities or insurers? Question General #5 - Section #390.3(e) Is the carrier knowledgeable of the FMCSRs/HMRs? Question General #6 - Section # Does the carrier know the commercial motor vehicles marking requirements?

6 Part B Questions and s An asterisk (*) beside an answer indicates an area of non-compliance by the motor carrier, and negatively affects the results of the audit. Question Driver #1 Section #391.51(a) Critical Does the carrier maintain complete driver qualification files? Driver files must contain the following items at a minimum: 1. Driver s Employment Application (10 years for CDL drivers, 3 for others ) Employment background check for prior 3 years per Copy of Medical Certificate (and waiver/spe if driver has on) / Copy of Road test Certificate g for completed road test or equivalent 4. Prior 3 years driving history from State Agency (e.g. DMV or MVR) b 5. Once per year an Annual record check for the driver consisting of the following: \ A. Driving history check from State Agency Must take into consideration any violations of the FMCSRs, HMRs and accident record. B. Drivers notation of ANY violations including those in a passenger car C. Carrier s signature indicating review complete and record satisfactory. *owner operators may complete B and C for themselves. = (c)(2)- **CDL Drivers must have alcohol/controlled substance background checks (e) Question Driver #2 Section #391.11(b)(4) Acute Is the carrier using physically qualified drivers? Question Driver #3 - Section #391.45(a), (b) Critical Does available evidence indicate the motor carrier has used a driver without a medical certificate or with an expired medical certificate? Question Driver #4 - Section #390.15(a) Acute Is the carrier using any disqualified drivers?

7 Part B Questions and s An asterisk (*) beside an answer indicates an area of non-compliance by the motor carrier, and negatively affects the results of the audit. Question Driver #5 Section #391.51(b)(2) Critical Does the carrier maintain driving and employment history inquiry data in driver qualification files? Missing documents include previous employer inquiry and driving history inquiry. Question Driver #6 Section # (a) Acute Has the carrier implemented an alcohol and/or controlled substances testing program? Question Driver #7 - Section # (b) Acute Has the carrier used drivers who have used controlled substances? Question Driver #8 - Section # Acute Has the carrier used a driver who has tested positive for a controlled substance? Question Driver #9 - Section # Acute Has the carrier used a driver known to have an alcohol concentration of 0.04 or greater? Question Driver #10 - Section # (a) Acute Has the carrier used a driver found to have an alcohol concentration of.02 or greater but less than.04 within 24 hours of being tested? Question Driver #11 - Section # (a) Critical Has the carrier ensured that drivers have undergone testing for controlled substances prior to performing a Safety sensitive function? Question Driver #12 - Section # (a) Critical Has the carrier conducted post accident testing on drivers for alcohol and/or controlled substances?

8 Part B Questions and s An asterisk (*) beside an answer indicates an area of non-compliance by the motor carrier, and negatively affects the results of the audit. Question Driver #13 Section # Acute Has the carrier implemented random testing program? Question Driver #14 Section # (b)(1) Critical Has the carrier conducted random alcohol testing at an annual rate of not less than the applicable annual rate of the average number of driver positions? Question Driver #15 - Section # (b)(2) Critical Has the carrier conducted controlled substance testing at an annual rate of not less than the applicable annual rate of the average number of driver positions? Question Driver #16 - Section # (a) Has the carrier conducted the required return-to-duty tests on employees returning to safety-sensitive functions? Question Driver #17 - Section # (a) Is the carrier conducting follow-up testing as directed by the Substance Abuse Professional? Question Driver #18 - Section # Acute Has the carrier used a driver who has refused to submit to an alcohol or controlled substances test required under Part 382? Question Driver #19 - Section # Critical Has the carrier used a Substance Abuse Professional as required by 49 CFR Part 40 Subpart O?

9 Part B Questions and s An asterisk (*) beside an answer indicates an area of non-compliance by the motor carrier, and negatively affects the results of the audit. Question Driver #20 Section #383.23(a) Critical Has a driver operated a commercial motor vehicle without a current operating license, or a license, which hasn t been properly classed and endorsed? Question Driver #21 Section #383.37(a) Acute Has the motor carrier allowed it s drivers who s CDLs have been suspended, revoked or canceled by a state, have lost the right to operate a CMV in a State, or have been disqualified from operating a CMV to operate a commercial motor vehicle? Question Driver #22 - Section #383.51(a) Acute Has the motor carrier knowingly allowed, required, permitted, or authorized a driver to drive who is disqualified to drive A commercial motor vehicle? Question Operation #1 - Section #395.8 (a) Critical Does the carrier require drivers to make a record of duty status? Question Operation #2 - Section #395.8 (i)(1) Critical Does the carrier require drivers to submit records of duty status within 13 days? Question Operation #3 - Section #395.8(k)(1) Critical Can the carrier produce records of duty status and supporting documents for selected drivers? Question Operation #4 - Section #395.3(a)(1) Critical Has the carrier allowed driver(s) to exceed the 11-hour rule? (Property) Question Operation #5 - Section #395.3(a)(2) Critical Has the carrier allowed driver(s) to exceed the 14-hour rule? (Property) Question Operation #6 - Section #395.3(b)(1) Critical Has the carrier allowed driver(s) to drive after having been on duty more than 60 hours in 7 consecutive days?

10 Part B Questions and s An asterick (*) beside an answer indicates an area of non-compliance by the motor carrier, and negatively affects the results of the audit. Question Operation #7 Section #395.3(b)(2) Critical Has the carrier allowed driver(s) to drive after having been on duty more than 70 hours in 8 consecutive days? (Property) Question Operation #8 Section #395.5(a)(1) Critical Has the carrier allowed driver(s) to exceed the 10-hour rule? (Passenger) Question Operation #9 - Section #395.5(a)(2) Critical Has the carrier allowed driver(s) to exceed the 15 hour rule? (Passenger) Question Operation #10 - Section #395.8(b)(1) Critical Has the carrier allowed driver(s) to drive after having been on duty more than 70 hours in 8 consecutive days? (Passenger) Question Operation #11 - Section #395.5 (b)(2) Critical Has the carrier allowed driver(s) to drive after having been on duty more than 70 hours in 8 consecutive days? (Passenger) Question Operation #12 - Section #395.8(e) Critical Does available evidence indicate a selected driver has prepared a false record on duty status? Question Operation #13 - Section # Does the carrier adhere to a disciplinary policy for noncompliance with part 395? Question Operation #14 - Section #395.1(e) Does the carrier have a system for recording hours of duty status on 100-mile radius drivers, and are they properly utilizing the 100 air-mile radius exemption? Question Operation #15 - Section #392.2 Critical Does the motor carrier ensure that drivers operate commercial motor vehicles in accordance with the laws, ordinances, and regulations of the jurisdictions in which they are operating?

11 Part B Questions and s An asterick (*) beside an answer indicates an area of non-compliance by the motor carrier, and negatively affects the results of the audit. Question Operation #16 Section #392.9(a)(1) Critical Does the carrier ensure that drivers are not permitted to drive a vehicle without the cargo properly distributed and adequately secured? Question Operation #17 Section #392.4(b) Acute Have any drivers operated a commercial motor vehicle while under the influence of, or in possession of, narcotic drugs, amphetamines, or any other substances capable of rendering the drivers incapable of safely operating motor vehicles? Question Operation #18 - Section #392.5(b)(1) Acute Have any drivers operated a commercial motor vehicle while under the influence of, or in possession of, intoxicating beverages? Question Operation #19 - Section #392.5(b)(2) Acute Have any drivers operated a commercial motor vehicle within 4 hours of having consumed intoxicating beverages. Question Maintenance #1 - Section #396.3(b) Critical Can the carrier produce maintenance files for requested vehicle(s)? Question Maintenance #2 - Section #396.17(a) Critical Can the motor carrier produce evidence of periodic (annual) inspections for selected vehicles?

12 Part B Questions and s An asterisk (*) beside an answer indicates an area of non-compliance by the motor carrier, and negatively affects the results of the audit. Question Maintenance #3 Section #396.11(a) Critical Does the Motor Carrier require drivers to complete vehicle inspection reports daily? Question Maintenance #4 Section #396.11(c) Acute Does the carrier ensure that out-of-service defects listed by the driver in the driver vehicle inspection reports are corrected before the vehicle is operated again? Question Maintenance #5 - Section #396.9 (c)(2) Acute Has the carrier allowed driver(s) to exceed the 15-hour rule? (Passenger) Question Maintenance #6 - Section # Is the carrier using qualified inspectors (mechanic) and maintaining evidence of the inspector s qualifications? Question Maintenance #7 - Section #396.3 Can the carrier explain its systematic, periodic maintenance program? Question Other #1 - Section # Does the carrier participate in an Arbitration Program? Question Other #2 - Section # Does the carrier adhere to a disciplinary policy for noncompliance with part 395?

13 Part B Questions and s An asterick (*) beside an answer indicates an area of non-compliance by the motor carrier, and negatively affects the results of the audit. Question Other #3 Section # (c) Does the carrier provide reasonably accurate estimates of moving charges? Question Other #4 Section # (a), (b) Has the carrier avoided hostage freight or other predatory practices? Question Other #5 - Section # (a), (b) Does the HHG carrier have sufficient levels of public liability and cargo insurance? Question Other #6 - Section #13901 Is the carrier using qualified inspectors (mechanic) and maintaining evidence of the inspector s qualifications?

14 Part B Your Proposed Safety Audit Results is: Pass or Fail Factor 1. General 2. Driver 3. Operations 4. Maintenance 5. Hazardous Materials 6. Accidents Explanation of Scoring Methodology Failed Questions Performance Critical Acute Test Status # # # # # # # # # # Total Points # # # # # # Factor Status SUM # # # NOTE: Carrier has the right to request a review of this determination if there are factual or procedural disputes. HOW THE SA IS SCORED FACTORS The Federal Motor Carrier Safety and Federal Hazardous Material Regulations are categorized into six factors. Multiple questions address the various factors. The Part B Questions & Report lists the CFR section numbers related to each questions. CRITICAL/ACUTE Questions are also defined as CRITICAL, ACUTE or neither depending on the significance of the underlying regulation. Questions are assigned a point value if they are incorrectly answered. Critical = 1 and acute = 1.5. The point values are summed for each factor. Any factor with a point value of 3 or more is marked FAILED. OUT OF SERVICE (OOS) RATE The Driver/Vehicle OOS rate is used in factor #4 as another question. If there have been more than three level 1, 2, or 5 North American Standard Inspections conducted over the past year, they will be summarized. If the summed OOS rate is over 34%, one additional point is assigned to that factor. CRASH FACTOR Carriers are defined as urban or non-urban in order to compensate or the higher crash risk of urban operations. Urban carriers are defined as those that operate within a 100 air-mile radius. The crash rate for a carrier is calculated as accidents per million miles traveled. Factor #6 is FAILED if the urban carrier crash rate exceeds 1.7 or the non-urban carrier crash rate exceeds 1.5. OVERALL STATUS DETERMINATION Any carrier with 3 or more FAILED factors is deemed to have failed the Safety Audit by having inadequate safety management controls in place to operate the U.S.

15 Part B Requirements and/or Recommendations 1. PLEASE NOTE: the violations discovered during this safety audit may affect the civil penalty proposed in any subsequent Notice of Claim. In addition, your history of prior violations of the Federal Motor Carrier Safety Regulations, Federal hazardous materials Regulations or the Federal Motor Carrier Commercial Regulations may also affect the civil penalty proposed in any subsequent Notice of Claim. Your signature for receipt of this report acknowledges your understanding that the violations discovered by the FMCSA during this safety audit may be used to calculate any civil penalty proposed as a result of any subsequent Notice of claim. Your signature is not an admission of the violations identified to you by the investigator. 2. Notice: On April 28, 2003 the FMCSA published a final rule revising the hours-of-service regulations for commercial motor vehicle drivers. Under the new rule, drivers may drive 11 hours after 10 consecutive hours off-duty, but may not drive beyond the 14 th hour after coming on-duty. Similar to existing rules, drivers may not drive after being on-duty for 60 hours in a seven-consecutive-day period or 70 hours in an eightconsecutive-day period. This on-duty cycle maybe restarted whenever a driver takes at least 4 consecutive hours off-duty. Short-haul truck drivers, who routinely return to their place of dispatch after each duty tour and then are released from duty, may have an increased on-duty period of 16 hours once during any seven consecutive day period. 3. Ensure that non-cdl drivers provide a 3-year employment history on their employment application, and that previous employment is verified in writing. 4. Ensure that CDL drivers provide a 10-year employment history on their employment application and this information is verified, in writing, by each previous employer. 5. Ensure that all drivers are fully and properly qualified before operating in interstate commerce. Maintain a complete file as required for each driver, documenting the qualified process. 6. Ensure that all drivers subject to pre=employment, random, reasonable cause, post accident, return to duty, and/or follow-up controlled substance testing are tested as required by 49 CFR Parts 40 and 382 of the FMCSR. 7. DOT drug testing rules require that employers test for marijuana, cocaine, opiates, amphetamines, and phencyclidine (PCP). 8. Maintain all required controlled substance testing records including yearly summaries, quarterly summaries, test information, test results, records of training etc., as required by 49 CFR Parts 40 and 382 of the FMCSR. 9. If you want some drivers to use the 100 air-mile radius exemption, make sure that the drivers meet all terms of the exemption, including being released from duty no more than 12 hours from when they report for duty. Logs must be prepared if a driver does not meet the 12 hour requirement. 10. If you want some drivers to use the 150 air-mile radius exemption, make sure that the drivers meet all terms of the exemption, including being released from duty no more than 12 hours from when they report for duty. Logs must be prepared if a driver does not meet the 12 hour requirement.

16 Part B Requirements and/or Recommendations 11. Obtain from any driver used for the first time (or intermittently) a signed statement showing the total time onduty during the preceding seven (7) days and the time at which the driver was last relieved from duty. 12. Ensure that all documents supporting records of duty status (such as toll fuel repair and other on-the-road expense receipts, as well as invoices, bills of lading, dispatch records, etc.) are kept on file for at least 6 months. 13. Ensure that all drivers records of duty status (logs) are accurate. Check them against supporting documents to verify accuracy. Prohibit falsification of logs by any driver. Review the rules on supporting documents. Take appropriate action against drivers who falsify logs. 14. Keep all driver vehicle inspection reports, signed, certified and reviewed as required on file for at least 90 days. 15. Establish a systematic maintenance records program for all vehicles. Maintain a complete file for each subject vehicle, recording all repair, maintenance and inspection operations performed. 16. Require all drivers to prepare a written inspection report for each day a vehicle is operated. Ensure that each report is signed by the driver, certified, and reviewed if defects are reported, then kept in the vehicle for a day. 17. Ensure that the persons or entities that perform preventative maintenance inspections on your equipment are avoiding by agreed time or mileage intervals. Ensure that records are kept of such periodic preventative maintenance inspections. Take corrective action, if schedules are not being adhered to.