Optima Batteries ChumpCar World Series – Safety & Tech Form 15-A 2015 SAFETY & TECHNICAL INSPECTION FORM RACETRACK: ___________________________________________ CAR NO. ______________________ TEAM NAME: ___________________________________________________________________________ TEAM CAPTAIN OR ENTRANT:___________________________________________________________ CAR YEAR / MAKE / MODEL/ COLOR: ____________________________________________________ CELL PHONE NUMBER AT TRACK: ______________________________________________________ (6) Laps w/Multiplier (5) Penalty Laps (4) Total Comp Value SAFETY INSPECTION • Roll Cage & Padding: • Racing Seat: • Seatbelt Harness: • Window Nets & Secure Attachment: • Arm Restraints: • Steering Wheel Lock Removed/Disabled: • Fire Extinguisher System: • Kill Switch: • Fuel, Oil, Coolant Line(s): • Optima Battery Installation and Isolation: • Fuel Tank or Fuel Cell: • Bulkheads / Wiring / Plumbing: • Glass and/or Lights Removed: • Window Attachment Hardware: • Window Support Straps: • Sunroofs, T-Tops, Convertibles: • Body Panel Attachments: • Transponder & Mount: • Exhaust System & Termination: • 2 Brake Lights: BCCR ITEMS • DOT / 180 TW Tires: • Minimum 60% Original Bodywork: • Max. 93 DbA Noise Limit: • Fuel Capacity +/- 2 Gallon/Stock: • Brakes to 2X Rule: • 2015 Sponsor Decals: • OFFICIAL ChumpCar Number Panel : • Approved Font / Size Numbers: NIGHT RACING • Night Racing - Number Panel Lights: • Night Racing - Min. 2 Brake / 2 Tail Lights: • Night Racing - Max. 4 Headlights: • Night Racing - Bulbs/LED to Rules: TOTAL COMP VALUE INSPECTION • Turbo/Supercharger: • Any adjustable shock: • Non-OE coil springs (including ‘coil-over’ kit): • Commercial adjustable camber/caster plates: • Homemade adjustable camber/caster plates: • Shock/Strut-tower reinforcement bar: • Non-OE suspension component: • Wheel spacers/hub adapters: • Non-OE sway-bar: • Non-OE radiator: • Non-OE & aftermarket aluminum radiator: • Non-OE oil cooler: • Oil Accumulator: • Dry-sump assembly: • Non-OE oil pan: • Exhaust Header: • Aftermarket Ignition Coil: • Performance distributor or ignition system: • Heim joint tie rods: • Non-OE suspension bushings: • Non-OE engine/transmission mounts: • Non-OE CV, driveshaft or axles: • Non-OE differential cover: • Non-OE ECU (incl. chip): • Non-OE carburetion, induction or metering : • Non-OE cylinder head(s): • Non-OE camshaft or valve train: • Non-OE master cylinder: • Non-OE proportioning valve: • Brakes in excess of 2X Rule: • Excessive Roll-cage Bars (tube frame): • Custom machine / fabrication work: • Plywood Material: • Sheet Aluminum / Steel: • Polycarbonate / Plexiglass / Plastic: • Carbon-fiber: OTHER • • • • (3) MPV (2) Swap Value (1) Value-Add Item Value-Add Sub-Total Ave. New/Used (TBD) Move to EC $20/corner $20 F / $20 R $5 F / $5 R $20 each $10 per unit $5 each $50 F / $30 R $5 $35 $20 $10 $500 $75 $50 $30 $50 $5 each $25/car $10 $50 $10 $75 $100 $150 $100 $50 $25 TBD $10 per bar $75/hr Fab. $1 / SQ. FT. $2 / SQ. FT. $3 / SQ. FT. $5 / SQ. FT. OTHER • • • • $ $ $ $ Reviewed and Approved by ChumpCar Tech: TEAM CAPTAIN OR ENTRANT: I have prepared, entered and inspected this vehicle and take full responsibility for its condition. I understand that this tech inspection is in no way a certification, representation, or guarantee that this vehicle meets or exceeds any standard of safety or represents any standard of use, and that this inspection does not imply any acceptance of liability on the part of the inspectors, the track, or the organizers of this motorsports event. I agree to indemnify and hold harmless ChumpCar International LLC and the Optima/ChumpCar World Series, its owners, officers, sponsors, agents, employees and associates from any claims, litigation, or liability arising from any person who makes any claim whatsoever in association with this inspection. Owner or Team Captain's Name: _________________________________ Signature: ________________________________ Date: __________ Once this form has been reviewed and approved by all ChumpCar inspectors and signed-off, the Team Captain must take this form to the registration table to receive the team's general acceptance packet.