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9001 -- 5. 9014 and in Chapter 2151 Texas Occupations Code. INSPECTOR DO NOT USE STAPLES ON PICTURES. PICTURE PAGE MUST HAVE BUSINESS NAME / RIDE NAME / SERIAL NUMBER AND DATE PICTURE IS TAKEN. Signature of Inspector Date Name and Title of Inspector Inspection Company - Cell Number Authorization of the Insurance Company Name and Title print Signature of Authorized Insurance Company Representative TDI Inspection Sticker Number TDI Amusement Ride Validation Stamp TDI FORM AR-100 Revised Effective October 2005 May 2000. TEXAS DEPARTMENT OF INSURANCE 333 Guadalupe P. O. Box 149104-Mail Code 103-9A Austin Texas 78714-9104 512 322-3435 Fax 512 305-7425 304-7425 Amusement Ride Certificate of Inspection/Reinspection Required for each ride pursuant to Texas Occupations Code Chapter 2151 Amusement Ride Safety Inspection and Insurance Act and 28 Texas Administrative Code 5. 9004 -- 5. 9014 Amusement Ride Rules along with a 40 per ride filing fee and picture of the ride in an operable state taken at the time of the inspection* PLEASE DO NOT USE STAPLES ON PICTURES. Owner/Operator Information Address St*/P. O. Box Telephone Number City State Zip Code Serial Number Manufacturer Date of Last Overhaul or Renovation Date of Last previous Inspection A Ride designed primarily for use by children 12 years of age or younger with a fixed location B Ride other than Class A I hereby certify that the above described Amusement Ride was inspected/reinspected in an operable state and meets the standards and requirements of Insurance Company and the inspection requirements as set forth in 28 TAC 5. TEXAS DEPARTMENT OF INSURANCE 333 Guadalupe P. O. Box 149104-Mail Code 103-9A Austin Texas 78714-9104 512 322-3435 Fax 512 305-7425 304-7425 Amusement Ride Certificate of Inspection/Reinspection Required for each ride pursuant to Texas Occupations Code Chapter 2151 Amusement Ride Safety Inspection and Insurance Act and 28 Texas Administrative Code 5. 9004 -- 5. 9014 Amusement Ride Rules along with a 40 per ride filing fee and picture of the ride in an operable state taken at the time of the inspection* PLEASE DO NOT USE STAPLES ON PICTURES. 9004 -- 5. 9014 Amusement Ride Rules along with a 40 per ride filing fee and picture of the ride in an operable state taken at the time of the inspection* PLEASE DO NOT USE STAPLES ON PICTURES. Owner/Operator Information Address St*/P. O. Box Telephone Number City State Zip Code Serial Number Manufacturer Date of Last Overhaul or Renovation Date of Last previous Inspection A Ride designed primarily for use by children 12 years of age or younger with a fixed location B Ride other than Class A I hereby certify that the above described Amusement Ride was inspected/reinspected in an operable state and meets the standards and requirements of Insurance Company and the inspection requirements as set forth in 28 TAC 5. TEXAS DEPARTMENT OF INSURANCE 333 Guadalupe P. O. Box 149104-Mail Code 103-9A Austin Texas 78714-9104 512 322-3435 Fax 512 305-7425 304-7425 Amusement Ride Certificate of Inspection/Reinspection Required for each ride pursuant to Texas Occupations Code Chapter 2151 Amusement Ride Safety Inspection and Insurance Act and 28 Texas Administrative Code 5. 9004 -- 5. 9014 Amusement Ride Rules along with a 40 per ride filing fee and picture of the ride in an operable state taken at the time of the inspection* PLEASE DO NOT USE STAPLES ON PICTURES. Owner/Operator Information Address St*/P. O. Box Telephone Number City State Zip Code Serial Number Manufacturer Date of Last Overhaul or Renovation Date of Last previous Inspection A Ride designed primarily for use by children 12 years of age or younger with a fixed location B Ride other than Class A I hereby certify that the above described Amusement Ride was inspected/reinspected in an operable state and meets the standards and requirements of Insurance Company and the inspection requirements as set forth in 28 TAC 5.