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Tahun 2017 PT Adhi Karya (Persero) Tbk

Divisi Konstruksi III


KARTU CEK LIS
ALAT GENERATING SET
/ GENSET
Jenis Alat : Genset
No Kode Alat : -
No Kode DK : -
Merk Alat/Mesin : AVK/Mitsubishi
Type Alat/Mesin : 6 D 40
No Seri Alat/Mesin : 261465
Kapasitas Alat/Mesin : 325 KVK
Status : Baik

Altenator                                    

Indikator Water Temperatur


ELECTRIC SYSTEM
Status :

Indikator Ampere

Indikator Voltage
þ Oke
Injection Pump

Tutup Radiator
ý Tidak (cek ulang)
Stop Enggine

Turbo Carge

Motor Stater
Tanggal

Generator
ENGGINE

Box Fuse
Fuel Fiter

Van Belt
Oil Filter

Radiator
Bulan

Air Filter

Battery
Stik Oil

RPM
10

1  

2  

3  

4  

5  

8  

9  
A


5
1

6
4
3

B
2

9
24 25
10 11 12 13 14 15 16 17 18 19 20 21 22 23

JANUARI
9
8
7
6
5
4
3
2
1
27 28 29 30 31
26

REKOMENDASI
Dengan hasil pengecekan tersebut diatas maka memberikan kesimpulan bahwa alat :Layak / Tidak Layak Pakai

Catatan : ..........................................................................................................................................................................................................................
...........................................................................................................................................................................................................................
Cirebon , ...........................2017
Mengetahui Diperiksa Diperiksa

( ................................. ) ( ................................. ) ( ................................. )


Peralatan QHSE Operator
Tahun 2017 PT Adhi Karya (Persero) Tbk
Divisi Konstruksi III
KARTU CEK LIS
ALAT AIR COMPRESOR

Jenis Alat : Air Compresor


No Kode Alat : J.01.0803.R.01
No Kode DK : CP 01
Merk Alat/Mesin : Airman/Isuzu
Type Alat/Mesin : PDS 175 S/C 240
No Seri Alat/Mesin: A 4270505/83795
Kapasitas Alat/Me : 175 CFM/50 HP
Status : Baik

Altenator                                    

Indikator Water Temperatur


ELECTRIC SYSTEM

Indikator Compresor
Status :

Selenoide Enggine

Saparator Hydrolic
Pump Compresor

Filter Oil Hydrolic


Indikator Ampere
þ Oke
Injection Pump

House Hydrolic
Tutup Radiator

ý Tidak (cek ulang)

House Meter
Motor Stater
Tanggal

Hand Break

C HYDROLIC
A ENGGINE

Fuel Fiter

Box Fuse
Van Belt
Kenalpot
Oil Filter

Radiator
Bulan

Air Filter

Battery

Stik Oil
Stik Oil

RPM

10  
10

1  

2  

3  

4  

5  

8  

9  

1  

2  

3  

5  
4  


5
1

B
3

7
2

8
9
24 25
21 22 23
13 14 15 16 17 18 19 20
10 11 12
9
8
7
6
5
4
3
2
1
30 31
27 28 29
26

REKOMENDASI
Dengan hasil pengecekan tersebut diatas maka memberikan kesimpulan bahwa alat :Layak / Tidak Layak Pakai

Catatan : ..........................................................................................................................................................................................................................
...........................................................................................................................................................................................................................
Cirebon , ...........................2017
Mengetahui Diperiksa Diperiksa

( ................................. ) ( ................................. ) ( ................................. )


Peralatan QHSE Operator
Tahun 2017 PT Adhi Karya (Persero) Tbk
Divisi Konstruksi III
KARTU CEK LIS
ALAT AIR COMPRESOR

Jenis Alat : Air Compresor


No Kode Alat :
No Kode DK :
Merk Alat/Mesin : Airman/Isuzu
Type Alat/Mesin : PDS 175 S/C 240
No Seri Alat/Mesin: /833212
Kapasitas Alat/Me : 175 CFM/50 HP
Status : Baik

Altenator                                    

Indikator Water Temperatur


ELECTRIC SYSTEM

Indikator Compresor
Status :

Selenoide Enggine

Saparator Hydrolic
Pump Compresor

Filter Oil Hydrolic


Indikator Ampere
þ Oke
Injection Pump

House Hydrolic
Tutup Radiator

ý Tidak (cek ulang)

House Meter
Motor Stater
Tanggal

Hand Break

C HYDROLIC
ENGGINE

Fuel Fiter

Box Fuse
Van Belt
Kenalpot
Oil Filter

Radiator
Bulan

Air Filter

Battery

Stik Oil
Stik Oil

RPM

10  
10

1  

2  

3  

4  

5  

8  

9  

1  

2  

3  

5  
4  
A


5
1

B
3

7
2

8
9
24 25
21 22 23
13 14 15 16 17 18 19 20
10 11 12
9
8
7
6
5
4
3
2
1
30 31
27 28 29
26

REKOMENDASI
Dengan hasil pengecekan tersebut diatas maka memberikan kesimpulan bahwa alat :Layak / Tidak Layak Pakai

Catatan : ..........................................................................................................................................................................................................................
...........................................................................................................................................................................................................................
Cirebon , ...........................2017
Mengetahui Diperiksa Diperiksa

( ................................. ) ( ................................. ) ( ................................. )


Peralatan QHSE Operator
Tahun 2017 PT Adhi Karya (Persero) Tbk
Divisi Konstruksi III
KARTU CEK LIS
ALAT AIR COMPRESOR

Jenis Alat : Air Compresor


No Kode Alat :
No Kode DK :
Merk Alat/Mesin : Airman/Yanmar
Type Alat/Mesin : PDS 185S-6C2/4TNV88-BDHKS
No Seri Alat/Mesin: B4-6C27259/W 4000
Kapasitas Alat/Me :
Status : Baik

Altenator                                    

Indikator Water Temperatur


ELECTRIC SYSTEM

Indikator Compresor
Status :

Selenoide Enggine

Saparator Hydrolic
Pump Compresor

Filter Oil Hydrolic


Indikator Ampere
þ Oke
Injection Pump

House Hydrolic
Tutup Radiator

Heand Breake ý Tidak (cek ulang)

House Meter
Motor Stater
Tanggal

C HYDROLIC
ENGGINE

Fuel Fiter

Box Fuse
Van Belt
Kenalpot
Oil Filter

Radiator
Bulan

Air Filter

Battery

Stik Oil
Stik Oil

RPM

10  
10

1  

2  

3  

4  

5  

8  

9  

1  

2  

3  

5  
4  
A


1

B
3

7
2

8
9
24 25
21 22 23
13 14 15 16 17 18 19 20
10 11 12
9
8
7
6
5
4
3
2
1
30 31
27 28 29
26

REKOMENDASI
Dengan hasil pengecekan tersebut diatas maka memberikan kesimpulan bahwa alat :Layak / Tidak Layak Pakai

Catatan : ..........................................................................................................................................................................................................................
...........................................................................................................................................................................................................................
Cirebon , ...........................2017
Mengetahui Diperiksa Diperiksa

( ................................. ) ( ................................. ) ( ................................. )


Peralatan QHSE Operator
Tahun 2017 PT Adhi Karya (Persero) Tbk
Divisi Konstruksi III
KARTU CEK LIS
ALAT TANDEM ROLLER

Jenis Alat : Tandem Roller


No Kode Alat : D.37.1003.R.01
No Kode DK : TD 11
Merk Alat/Mesin : Sakai/isuzu
Type Alat/Mesin : WM 7708/D 120
No Seri Alat/Mesin : WM 8 1990
Kapasitas Alat/Mesin : 8-10 Ton/75 HP
Status : Baik

Kopling Maju Mundur


Altenator                                    

Indikator Water Temperatur

Mundur
ELECTRIC SYSTEM
Status :

Indikator Ampere

Kampas Kopling
Kopling

Kopling

Kampas Kopling

Kampas Kopling
þ Oke
Injection Pump

House Hydrolic
Tutup Radiator

Pump Hydrolic
ý

Seal Cylinder
Tidak (c

House Meter

KampasMaju
Motor Stater
Tanggal

Hand Break

C HYDROLIC
Compresor
ENGGINE

TRANMISI
Fuel Fiter

Gear Box
Box Fuse
Van Belt

Selenoid
Kenalpot
Oil Filter

Radiator
Bulan

Kampas

Kampas
Air Filter

Klakson

Handel
Battery
Stik Oil

Lampu
Break

RPM

10  

D  
10

12
11

1  

2  

3  

4  

5  

9  

1  

2  

3  

1  

2  

3  

4  

5  
8  
A


5
1

6
3

B
2

8
9
24 25
21 22 23
10 11 12 13 14 15 16 17 18 19 20

I
9
8
7
6
5
4
3
2
1
30 31
27 28 29
26

REKOMENDASI
Dengan hasil pengecekan tersebut diatas maka memberikan kesimpulan bahwa alat :Layak / Tidak Layak Pakai

Catatan : ..........................................................................................................................................................................................................................
...........................................................................................................................................................................................................................
Cirebon , ...........................2017
Mengetahui Diperiksa Diperiksa

( ................................. ) ( ................................. ) ( ................................. )


Peralatan QHSE Operator
Tahun 2017 PT Adhi Karya (Persero) Tbk
Divisi Konstruksi III
KARTU CEK LIS
ALAT TANDEM ROLLER

Jenis Alat : Tandem Double Vibrating Roller


No Kode Alat : D.37.1003.R.04
No Kode DK : TDV 03
Merk Alat/Mesin : hasselberg/Bomag/Deutz
Type Alat/Mesin : BW 151 A/F 4 L 912
No Seri Alat/Mesin : WM 8 1990
Kapasitas Alat/Mesin : 8-10 Ton/210 HP
Status : Rusak

Kopling Maju Mundur


Altenator                                    

Indikator Water Temperatur

Mundur
ELECTRIC SYSTEM
Status :

Indikator Ampere

Kampas Kopling
Kopling

Kopling

Kampas Kopling

Kampas Kopling
þ Oke
Injection Pump

House Hydrolic
Tutup Radiator

Pump Hydrolic

Seal Cylinder
ý Tidak (c

House Meter

KampasMaju
Motor Stater
Tanggal

Hand Break

C HYDROLIC
Compresor
ENGGINE

TRANMISI
Fuel Fiter

Gear Box
Box Fuse
Van Belt

Selenoid
Kenalpot
Oil Filter

Radiator
Bulan

Kampas

Kampas
Air Filter

Klakson

Handel
Battery
Stik Oil

Lampu
Break

RPM

10  

D  
10

12
11

1  

2  

3  

4  

5  

9  

1  

2  

3  

1  

2  

3  

4  

5  
8  
A


5
1

B
3

7
2

8
9
24 25
21 22 23
13 14 15 16 17 18 19 20
10 11 12
9
8
7
6
5
4
3
2
1
30 31
27 28 29
26

REKOMENDASI
Dengan hasil pengecekan tersebut diatas maka memberikan kesimpulan bahwa alat :Layak / Tidak Layak Pakai

Catatan : ..........................................................................................................................................................................................................................
...........................................................................................................................................................................................................................
Cirebon , ...........................2017
Mengetahui Diperiksa Diperiksa

( ................................. ) ( ................................. ) ( ................................. )


Peralatan QHSE Operator
Tahun 2017 PT Adhi Karya (Persero) Tbk
Divisi Konstruksi III
KARTU CEK LIS
ALAT TANDEM ROLLER

Jenis Alat : Tandem Roller


No Kode Alat : −
No Kode DK : −
Merk Alat/Mesin : Sakai/isuzu
Type Alat/Mesin : SW-652H-1K
No Seri Alat/Mesin : 1SW52-20345/V3307T-8GL5805
Kapasitas Alat/Mesin : −
Status : Baik

Kopling Maju Mundur


Altenator                                    

Indikator Water Temperatur

Mundur
ELECTRIC SYSTEM
Status :

Indikator Ampere

Kopling

Kopling

Kampas Kopling
Kampas Kopling

Kampas Kopling
þ Oke
Injection Pump

House Hydrolic
Tutup Radiator

Pump Hydrolic
ý

Seal Cylinder
Tidak (c

House Meter

KampasMaju
Motor Stater
Tanggal

Hand Break

C HYDROLIC
Compresor
ENGGINE

TRANMISI
Fuel Fiter

Gear Box
Box Fuse
Van Belt

Selenoid
Kenalpot
Oil Filter

Radiator
Bulan

Kampas

Kampas
Air Filter

Klakson

Handel
Battery
Stik Oil

Lampu
Break

RPM

10  

D  
10

12
11

1  

2  

3  

4  

5  

9  

1  

2  

3  

1  

2  

3  

4  

5  
8  
A


5
1

6
3

B
2

8
9
24 25
21 22 23
10 11 12 13 14 15 16 17 18 19 20
9
8
7
6
5
4
3
2
1
30 31
27 28 29
26

REKOMENDASI
Dengan hasil pengecekan tersebut diatas maka memberikan kesimpulan bahwa alat :Layak / Tidak Layak Pakai

Catatan : ..........................................................................................................................................................................................................................
...........................................................................................................................................................................................................................
Cirebon , ...........................2017
Mengetahui Diperiksa Diperiksa

( ................................. ) ( ................................. ) ( ................................. )


Peralatan QHSE Operator
PT Adhi Karya (Persero) Tbk
Divisi Konstruksi III

Status :

ý Tidak (cek ulang)


PT Adhi Karya (Persero) Tbk
Divisi Konstruksi III

Status :

ý Tidak (cek ulang)


PT Adhi Karya (Persero) Tbk
Divisi Konstruksi III

Status :

ý Tidak (cek ulang)


Tahun 2017 PT Adhi Karya (Persero) Tbk
Divisi Konstruksi III
KARTU CEK LIS
ALAT WHELL LOADER

Jenis Alat : Whell Loader


No Kode Alat : -
No Kode DK : -
Merk Alat/Mesin : Furukawa/Nissan
Type Alat/Mesin : FL 345/NE 6
No Seri Alat/Mesin : -
Kapasitas Alat/Mesin : 3,5 M³
Status : Baik

Altenator                                    

Indikator Water Temperatur


ELECTRIC SYSTEM

Deferensial Gardan
Status :

Selenoid Hydrolic
Filter Oil Hydrolic
Indikator Ampere

Join Kopling

Kampas Kopling
Kopling

Kampas Kopling

Oil Kopling

Kampas Kopling
þ Oke

Oil Tranmisi
Injection Pump

House Hydrolic
Tutup Radiator

Pump Hydrolic
Turbbo Carger

Seal Cylinder
ý Tidak (cek ulang)

House Meter
Motor Stater
Tanggal

Hand Break

C HYDROLIC
ENGGINE

Pin Bucket

TRANMISI
Fuel Fiter

Box Fuse
Van Belt

Selenoid
Kenalpot
Oil Filter

Radiator
Bulan

Kampas

Kampas

Kampas
Kampas
Air Filter

Klakson
Battery
Stik Oil

Lampu

Bucket

Pump
Break

Filter
RPM

Bolt
Stik
10  

D  
10

12

9  

2  

4  
11

1  

2  

3  

4  

5  

8  

1  

3  

5  

7  

1  

2  

3  

4  

5  
A


5
1

B
3

7
2

8
9
24 25
21 22 23
10 11 12 13 14 15 16 17 18 19 20
9
8
7
6
5
4
3
2
1
30 31
27 28 29
26

REKOMENDASI
Dengan hasil pengecekan tersebut diatas maka memberikan kesimpulan bahwa alat :Layak / Tidak Layak Pakai

Catatan : ..........................................................................................................................................................................................................................
...........................................................................................................................................................................................................................
Cirebon , ...........................2017
Mengetahui Diperiksa Diperiksa

( ................................. ) ( ................................. ) ( ................................. )


Peralatan QHSE Operator
Tahun 2017 PT Adhi Karya (Persero) Tbk
Divisi Konstruksi III
KARTU CEK LIS
ALAT WHELL LOADER

Jenis Alat : Whell Loader


No Kode Alat : -
No Kode DK : -
Merk Alat/Mesin : Caterpilar
Type Alat/Mesin : WL 936 E
No Seri Alat/Mesin : -
Kapasitas Alat/Mesin : 2,3 M³
Status : Baik

Paraf dan
Altenator                                    

Indikator Water Temperatur


Keterangan
ELECTRIC SYSTEM

Deferensial Gardan
Status :

Selenoid Hydrolic
Filter Oil Hydrolic
Indikator Ampere

Join Kopling

Kampas Kopling
Kopling

Kampas Kopling

Oil Kopling

Kampas Kopling
þ Oke

Oil Tranmisi
Injection Pump

House Hydrolic
Tutup Radiator

Pump Hydrolic
Turbbo Carger

Seal Cylinder
ý Tidak (cek ulang)

House Meter
Motor Stater
Tanggal

Hand Break

C HYDROLIC
ENGGINE

Pin Bucket

TRANMISI
Fuel Fiter

Box Fuse

Selenoid
Van Belt
Kenalpot
Oil Filter
Bulan

Radiator

Kampas

Kampas

Kampas
Kampas
Air Filter

Klakson
Battery
Stik Oil

Lampu

Bucket

Pump
Break

Filter
RPM

Bolt
Stik
10  

D  
10

12

9  

2  

4  
11

1  

2  

3  

4  

5  

8  

1  

3  

5  

7  

1  

2  

3  

4  

5  
A


5
1

B
3

7
2

8
9
24 25
21 22 23
10 11 12 13 14 15 16 17 18 19 20

I
9
8
7
6
5
4
3
2
1
30 31
27 28 29
26

REKOMENDASI
Dengan hasil pengecekan tersebut diatas maka memberikan kesimpulan bahwa alat :Layak / Tidak Layak Pakai

Catatan : ..........................................................................................................................................................................................................................
...........................................................................................................................................................................................................................
Cirebon , ...........................2017
Mengetahui Diperiksa Diperiksa

( ................................. ) ( ................................. ) ( ................................. )


Peralatan QHSE Operator
Tahun 2017 PT Adhi Karya (Persero) Tbk
Divisi Konstruksi III
KARTU CEK LIS
ALAT WHELL LOADER

Jenis Alat : Whell Loader


No Kode Alat : -
No Kode DK : -
Merk Alat/Mesin : Komatsu/
Type Alat/Mesin : WA 360Z
No Seri Alat/Mesin : -
Kapasitas Alat/Mesin : 4 M³
Status : Baik

Paraf dan
Altenator                                    

Indikator Water Temperatur


Keterangan
ELECTRIC SYSTEM

Deferensial Gardan
Status :

Selenoid Hydrolic
Filter Oil Hydrolic
Indikator Ampere

Join Kopling

Kampas Kopling
Kopling

Kampas Kopling

Oil Kopling

Kampas Kopling
þ Oke

Oil Tranmisi
Injection Pump

House Hydrolic
Tutup Radiator

Pump Hydrolic
Turbbo Carger

Seal Cylinder
ý Tidak (cek ulang)

House Meter
Motor Stater
Tanggal

Hand Break

C HYDROLIC
ENGGINE

Pin Bucket

TRANMISI
Fuel Fiter

Box Fuse
Van Belt

Selenoid
Kenalpot
Oil Filter

Radiator
Bulan

Kampas

Kampas

Kampas
Kampas
Air Filter

Klakson
Battery
Stik Oil

Lampu

Bucket

Pump
Break

Filter
RPM

Bolt
Stik
10  

D  
10

12

9  

2  

4  
11

1  

2  

3  

4  

5  

8  

1  

3  

5  

7  

1  

2  

3  

4  

5  
A


5
1

B
3

7
2

8
9
24 25
21 22 23
10 11 12 13 14 15 16 17 18 19 20

I
9
8
7
6
5
4
3
2
1
27 28 29 30 31
26

REKOMENDASI
Dengan hasil pengecekan tersebut diatas maka memberikan kesimpulan bahwa alat :Layak / Tidak Layak Pakai

Catatan : ..........................................................................................................................................................................................................................
...........................................................................................................................................................................................................................
Cirebon , ...........................2017
Mengetahui Diperiksa Diperiksa

( ................................. ) ( ................................. ) ( ................................. )


Peralatan QHSE Operator
Tahun 2017 PT Adhi Karya (Persero) Tbk
Divisi Konstruksi III
KARTU CEK LIS
ALAT DUMP TRUCK

Jenis Alat : Dump Truck H 1561 UH


No Kode Alat : F.02.0991.B.168
No Kode DK : DT 11
Merk Alat/Mesin : Nissan/Nissan
Type Alat/Mesin : CPB 14 F/NE 6
No Seri Alat/Mesin : 208/184
Kapasitas Alat/Mesin : 9 Ton/177 HP
Status : Baik

Altenator                                    

Indikator Water Temperatur


ELECTRIC SYSTEM

Join PumP Hydrolic


Status :

Diferensial Gardan

Join Kopling

JoinKopling

Kampas Kopling
Kampas Kopling
þ Oke
Injection Pump

House Hydrolic
Tutup Radiator

Pump Hydrolic

Seal Cylinder
ý Tidak (cek ulang)

Lampu Besar
Motor Stater
Tanggal

Hand Break
Hand Break

C HYDROLIC
7  Lampu Sen
ENGGINE

TRANMISI
Fuel Fiter

Selenoid
Kenalpot
Oil Filter

Radiator
Bulan

Kampas

Kampas
Air Filter

Klakson
Battery
Stik Oil

Break

Wiper

Break

Yuke
Bolt
10  

D  
10

1  

2  

3  

4  

5  

8  

9  

1  

2  

3  

1  

2  

3  

4  
4  
A


5
1

B
3

7
2

8
9
24 25
21 22 23
13 14 15 16 17 18 19 20
10 11 12
9
8
7
6
5
4
3
2
1
30 31
27 28 29
26

REKOMENDASI
Dengan hasil pengecekan tersebut diatas maka memberikan kesimpulan bahwa alat :Layak / Tidak Layak Pakai

Catatan : ..........................................................................................................................................................................................................................
...........................................................................................................................................................................................................................
Cirebon , ...........................2017
Mengetahui Diperiksa Diperiksa

( ................................. ) ( ................................. ) ( ................................. )


Peralatan QHSE Operator
Tahun 2017 PT Adhi Karya (Persero) Tbk
Divisi Konstruksi III
KARTU CEK LIS
ALAT DUMP TRUCK

Jenis Alat : Dump Truck B 9169 FQ


No Kode Alat : F.02.0991.B.170
No Kode DK : DT 14
Merk Alat/Mesin : Nissan/Nissan
Type Alat/Mesin : CKA 12 A/NE 6
No Seri Alat/Mesin : 21566/014392Y
Kapasitas Alat/Mesin : 9 Ton/177 HP
Status : Baik

Altenator                                    

Indikator Water Temperatur


ELECTRIC SYSTEM

Join PumP Hydrolic


Status :

Diferensial Gardan

Join Kopling

JoinKopling

Kampas Kopling
Kampas Kopling
þ Oke
Injection Pump

House Hydrolic
Tutup Radiator

Pump Hydrolic

Seal Cylinder
Lampu Besar
ý Tidak (cek ulang)

Motor Stater
Tanggal

Hand Break
Hand Break

C HYDROLIC
7  Lampu Sen
ENGGINE

TRANMISI
Fuel Fiter

Selenoid
Kenalpot
Oil Filter

Radiator
Bulan

Kampas

Kampas
Air Filter

Klakson
Battery
Stik Oil

Break

Wiper

Break

Yuke
Bolt
10  

D  
10

1  

2  

3  

4  

5  

8  

9  

1  

2  

3  

1  

2  

3  

4  
4  
A


5
1

B
3

7
2

8
9
24 25
21 22 23
13 14 15 16 17 18 19 20
10 11 12
9
8
7
6
5
4
3
2
1
30 31
27 28 29
26

REKOMENDASI
Dengan hasil pengecekan tersebut diatas maka memberikan kesimpulan bahwa alat :Layak / Tidak Layak Pakai

Catatan : ..........................................................................................................................................................................................................................
...........................................................................................................................................................................................................................
Cirebon , ...........................2017
Mengetahui Diperiksa Diperiksa

( ................................. ) ( ................................. ) ( ................................. )


Peralatan QHSE Operator
Tahun 2017 PT Adhi Karya (Persero) Tbk
Divisi Konstruksi III
KARTU CEK LIS
ALAT DUMP TRUCK

Jenis Alat : Dump Truck B 9171 FQ


No Kode Alat : F.02.0991.B.172
No Kode DK : DT 16
Merk Alat/Mesin : Nissan/Nissan
Type Alat/Mesin : CKA 12 A/NE 6
No Seri Alat/Mesin : 21568/014394Y
Kapasitas Alat/Mesin : 9 Ton/177 HP
Status : Baik

Altenator                                    

Indikator Water Temperatur


ELECTRIC SYSTEM

Join PumP Hydrolic


Status :

Diferensial Gardan

Join Kopling

JoinKopling

Kampas Kopling
Kampas Kopling
þ Oke
Injection Pump

House Hydrolic
Tutup Radiator

Pump Hydrolic

Seal Cylinder
ý Tidak (cek ulang)

Lampu Besar
Motor Stater
Tanggal

Hand Break
Hand Break

C HYDROLIC
7  Lampu Sen
ENGGINE

TRANMISI
Fuel Fiter

Selenoid
Kenalpot
Oil Filter

Radiator
Bulan

Kampas

Kampas
Air Filter

Klakson
Battery
Stik Oil

Break

Wiper

Break

Yuke
Bolt
10  

D  
10

1  

2  

3  

4  

5  

8  

9  

1  

2  

3  

1  

2  

3  

4  
4  
A


5
1

B
3

7
2

8
9
24 25
21 22 23
13 14 15 16 17 18 19 20
10 11 12
9
8
7
6
5
4
3
2
1
30 31
27 28 29
26

REKOMENDASI
Dengan hasil pengecekan tersebut diatas maka memberikan kesimpulan bahwa alat :Layak / Tidak Layak Pakai

Catatan : ..........................................................................................................................................................................................................................
...........................................................................................................................................................................................................................
Cirebon , ...........................2017
Mengetahui Diperiksa Diperiksa

( ................................. ) ( ................................. ) ( ................................. )


Peralatan QHSE Operator
Tahun 2017 PT Adhi Karya (Persero) Tbk
Divisi Konstruksi III
KARTU CEK LIS
ALAT DUMP TRUCK

Jenis Alat : Dump Truck B 9985 D


No Kode Alat : F.02.0903.R.02
No Kode DK : DT 44
Merk Alat/Mesin : Fuso/Mitsubishi
Type Alat/Mesin : FV 419 J/8 DC 9
No Seri Alat/Mesin : FV 4195J750562/8 DC 9435279
Kapasitas Alat/Mesin : 25 Ton/16031 HP
Status : Baik

Altenator                                    

Indikator Water Temperatur


ELECTRIC SYSTEM

Join PumP Hydrolic


Status :

Diferensial Gardan

Join Kopling

JoinKopling

Kampas Kopling
Kampas Kopling
þ Oke
Injection Pump

House Hydrolic
Tutup Radiator

Pump Hydrolic

Seal Cylinder
ý Tidak (cek ulang)

Lampu Besar
Motor Stater
Tanggal

Hand Break
Hand Break

C HYDROLIC
7  Lampu Sen
ENGGINE

TRANMISI
Fuel Fiter

Selenoid
Kenalpot
Oil Filter

Radiator
Bulan

Kampas

Kampas
Air Filter

Klakson
Battery
Stik Oil

Break

Wiper

Break

Yuke
Bolt
10  

D  
10

1  

2  

3  

4  

5  

8  

9  

1  

2  

3  

1  

2  

3  

4  
4  
A


5
1

B
3

7
2

8
9
24 25
21 22 23
13 14 15 16 17 18 19 20
10 11 12
9
8
7
6
5
4
3
2
1
30 31
27 28 29
26

REKOMENDASI
Dengan hasil pengecekan tersebut diatas maka memberikan kesimpulan bahwa alat :Layak / Tidak Layak Pakai

Catatan : ..........................................................................................................................................................................................................................
...........................................................................................................................................................................................................................
Cirebon , ...........................2017
Mengetahui Diperiksa Diperiksa

( ................................. ) ( ................................. ) ( ................................. )


Peralatan QHSE Operator
Tahun 2017 PT Adhi Karya (Persero) Tbk
Divisi Konstruksi III
KARTU CEK LIS
ALAT DUMP TRUCK

Jenis Alat : Dump Truck B 9983 D


No Kode Alat : F.02.0903.R.03
No Kode DK : DT 45
Merk Alat/Mesin : Fuso/Mitsubishi
Type Alat/Mesin : FV 415 J/8 DC 9
No Seri Alat/Mesin : FV 415 J 750557/8 DC 9435169
Kapasitas Alat/Mesin : 25 Ton/16031 HP
Status : Baik

Altenator                                    

Indikator Water Temperatur


ELECTRIC SYSTEM

Join PumP Hydrolic


Status :

Diferensial Gardan

Join Kopling

JoinKopling

Kampas Kopling
Kampas Kopling
þ Oke
Injection Pump

House Hydrolic
Tutup Radiator

Pump Hydrolic

Seal Cylinder
ý Tidak (cek ulang)

Lampu Besar
Motor Stater
Tanggal

Hand Break
Hand Break

C HYDROLIC
7  Lampu Sen
ENGGINE

TRANMISI
Fuel Fiter

Selenoid
Kenalpot
Oil Filter

Radiator
Bulan

Kampas

Kampas
Air Filter

Klakson
Battery
Stik Oil

Break

Wiper

Break

Yuke
Bolt
10  

D  
10

1  

2  

3  

4  

5  

8  

9  

1  

2  

3  

1  

2  

3  

4  
4  
A


1

B
3

7
2

8
9
24 25
21 22 23
13 14 15 16 17 18 19 20
10 11 12
9
8
7
6
5
4
3
2
1
30 31
27 28 29
26

REKOMENDASI
Dengan hasil pengecekan tersebut diatas maka memberikan kesimpulan bahwa alat :Layak / Tidak Layak Pakai

Catatan : ..........................................................................................................................................................................................................................
...........................................................................................................................................................................................................................
Cirebon , ...........................2017
Mengetahui Diperiksa Diperiksa

( ................................. ) ( ................................. ) ( ................................. )


Peralatan QHSE Operator
Tahun 2017 PT Adhi Karya (Persero) Tbk
Divisi Konstruksi III
KARTU CEK LIS
ALAT SPRAYER

Jenis Alat : Aspalt Sprayer


No Kode Alat : E.05.0090.B.13
No Kode DK : AS 11
Merk Alat/Mesin : Anugrah / Kubota
Type Alat/Mesin : AAS 850 / RD 55 HKI 07109
No Seri Alat/Mesin : 990.850.00
Kapasitas Alat/Mesin : 850 Ltr
Status : Baik

Status :

                                    

Kampas Kopling

Kampas Kopling

Kampas Kopling
þ Oke
Selang Spray
Spuyer Spray

ý Tidak (cek ulang)


Selah Engkol

Pump Spray
Tanggal

ENGGINE

Fuel Filter

Radiator

Selenoid
Air Filter
Bulan

Van Belt
Stik Oil
A

5
1

6
3

7
2

8
9

  

  

  

  

  

  

  

  

  

  
  

  
 

 
24 25
21 22 23
13 14 15 16 17 18 19 20
10 11 12

J
9
8
7
6
5
4
3
2
1
30 31
27 28 29
26

REKOMENDASI
Dengan hasil pengecekan tersebut diatas maka memberikan kesimpulan bahwa alat :Layak / Tidak Layak Pakai

Catatan : ..........................................................................................................................................................................................................................
...........................................................................................................................................................................................................................
Cirebon , ...........................2017
Mengetahui Diperiksa Diperiksa

( ................................. ) ( ................................. ) ( ................................. )


Peralatan QHSE Operator
Tahun 2017 PT Adhi Karya (Persero) Tbk
Divisi Konstruksi III
KARTU CEK LIS
ALAT SPRAYER

Jenis Alat : Aspalt Sprayer


No Kode Alat : -
No Kode DK : -
Merk Alat/Mesin : Dong Peng
Type Alat/Mesin : R 175 A
No Seri Alat/Mesin : 14121674
Kapasitas Alat/Mesin : 7 Hp / 2600 Rpm
Status : Baik

Status :

                                    

Kampas Kopling

Kampas Kopling

Kampas Kopling
þ Oke
Selang Spray
Spuyer Spray

ý Tidak (cek ulang)


Selah Engkol

Pump Spray
Tanggal

ENGGINE

Fuel Filter

Radiator

Selenoid
Air Filter
Bulan

Van Belt
Stik Oil
A

5
1

6
3

7
2

8
9

  

  

  

  

  

  

  

  

  

  
  

  
 

 
24 25
21 22 23
13 14 15 16 17 18 19 20
10 11 12
9
8
7
6
5
4
3
2
1
30 31
27 28 29
26

REKOMENDASI
Dengan hasil pengecekan tersebut diatas maka memberikan kesimpulan bahwa alat :Layak / Tidak Layak Pakai

Catatan : ..........................................................................................................................................................................................................................
...........................................................................................................................................................................................................................
Cirebon , ...........................2017
Mengetahui Diperiksa Diperiksa

( ................................. ) ( ................................. ) ( ................................. )


Peralatan QHSE Operator
Tahun 2017 PT Adhi Karya (Persero) Tbk
Divisi Konstruksi III
KARTU CEK LIS
ALAT TAMPING RAMMER

Jenis Alat : Tamping Rammer


No Kode Alat :
No Kode DK :
Merk Alat/Mesin : Dynamic/Honda
Type Alat/Mesin : DTR85H/GX-160
No Seri Alat/Mesin : GCAAH-4696378
Kapasitas Alat/Mesin :
Status : Baik

Status :

                                    

Kampas Kopling

Kampas Kopling

Kampas Kopling
þ Oke
ý Tidak (cek ulang)
Tanggal

Karburator
ENGGINE

Fuel Filter

Selenoid
Air Filter
Bulan

Stik Oil

6 Knalpot
Starter

7 Baut
A

5
1

4
3
2

8
9

  

  

  

  

  

  

  

  

  

  
  

  
 

 
24 25
21 22 23
13 14 15 16 17 18 19 20
10 11 12
9
8
7
6
5
4
3
2
1
30 31
27 28 29
26

REKOMENDASI
Dengan hasil pengecekan tersebut diatas maka memberikan kesimpulan bahwa alat :Layak / Tidak Layak Pakai

Catatan : ..........................................................................................................................................................................................................................
...........................................................................................................................................................................................................................
Cirebon , ...........................2017
Mengetahui Diperiksa Diperiksa

( ................................. ) ( ................................. ) ( ................................. )


Peralatan QHSE Operator
Tahun 2017 PT Adhi Karya (Persero) Tbk
Divisi Konstruksi III
KARTU CEK LIS
ALAT TAMPING RAMMER

Jenis Alat : Tamping Rammer


No Kode Alat :
No Kode DK :
Merk Alat/Mesin : Dynamic/Honda
Type Alat/Mesin : DTR85H/GX-160
No Seri Alat/Mesin : GCAAH-4696381
Kapasitas Alat/Mesin :
Status : Baik

Status :
þ Oke

                                    

Kampas Kopling

Kampas Kopling

Kampas Kopling
ý Tidak (cek ulang)
Tanggal

ENGGINE

Karburator
Fuel Filter

Selenoid
Air Filter
Bulan

Stik Oil

Knalpot
Starter

Baut
A
1

6
3

  

  

  

  

  

  

  

  

  

  
  

  
 

 
5
4

7
2

8
9
24 25
21 22 23
13 14 15 16 17 18 19 20
10 11 12
9
8
7
6
5
4
3
2
1
30 31
27 28 29
26

REKOMENDASI
Dengan hasil pengecekan tersebut diatas maka memberikan kesimpulan bahwa alat :Layak / Tidak Layak Pakai

Catatan : ..........................................................................................................................................................................................................................
...........................................................................................................................................................................................................................
Cirebon , ...........................2017
Mengetahui Diperiksa Diperiksa

( ................................. ) ( ................................. ) ( ................................. )


Peralatan QHSE Operator
Tahun 2017 PT Adhi Karya (Persero) Tbk
Divisi Konstruksi III
KARTU CEK LIS
ALAT TRAVO LAS

Jenis Alat : Travo Las


No Kode Alat :
No Kode DK :
Merk Alat/Mesin : Black Rino
Type Alat/Mesin :
No Seri Alat/Mesin :
Kapasitas Alat/Mesin :
Status : Baik

Status :

                                    

Kampas Kopling

Kampas Kopling

Kampas Kopling
þ Oke
Kabel Elektroda

Stang Elektroda

ý Tidak (cek ulang)


Babel Massa

Amper Meter

6 Stang Massa
Input Power
Tanggal

ENGGINE

Selenoid
Bulan

5
1

4
3
2

  

  

  

  

  

  

  

  

  

  
  

  
 

 
24 25
21 22 23
13 14 15 16 17 18 19 20
10 11 12
9
8
7
6
5
4
3
2
1
30 31
27 28 29
26

REKOMENDASI
Dengan hasil pengecekan tersebut diatas maka memberikan kesimpulan bahwa alat :Layak / Tidak Layak Pakai

Catatan : ..........................................................................................................................................................................................................................
...........................................................................................................................................................................................................................
Cirebon , ...........................2017
Mengetahui Diperiksa Diperiksa

( ................................. ) ( ................................. ) ( ................................. )


Peralatan QHSE Operator
Tahun 2017 PT Adhi Karya (Persero) Tbk
Divisi Konstruksi III
KARTU CEK LIS
ALAT TRAVO LAS

Jenis Alat : Travo Las


No Kode Alat :
No Kode DK :
Merk Alat/Mesin :
Type Alat/Mesin :
No Seri Alat/Mesin :
Kapasitas Alat/Mesin :
Status : Baik

Status :

                                    

Kampas Kopling

Kampas Kopling

Kampas Kopling
þ Oke
Kabel Elektroda

Stang Elektroda

ý Tidak (cek ulang)


Babel Massa

Amper Meter

Stang Massa
Input Power
Tanggal

ENGGINE

Selenoid
Bulan

A
1

6
3

  

  

  

  

  

  

  

  

  

  
  

  
 

 
5
4
2
24 25
21 22 23
13 14 15 16 17 18 19 20
10 11 12
9
8
7
6
5
4
3
2
1
30 31
6 27 28 29
2

REKOMENDASI
Dengan hasil pengecekan tersebut diatas maka memberikan kesimpulan bahwa alat :Layak / Tidak Layak Pakai

Catatan : ..........................................................................................................................................................................................................................
...........................................................................................................................................................................................................................
Cirebon , ...........................2017
Mengetahui Diperiksa Diperiksa

( ................................. ) ( ................................. ) ( ................................. )


Peralatan QHSE Operator
Tahun 2017 PT Adhi Karya (Persero) Tbk
Divisi Konstruksi III
KARTU CEK LIS
ALAT TRAVO LAS

Jenis Alat : Travo Las


No Kode Alat :
No Kode DK :
Merk Alat/Mesin :
Type Alat/Mesin :
No Seri Alat/Mesin :
Kapasitas Alat/Mesin :
Status : Baik

Status :

                                      

Kampas Kopling

   Kampas Kopling
Kampas Kopling
þ Oke
2 Kabel Elektroda

5 Stang Elektroda

ý Tidak (cek ulang)


3 Babel Massa

4 Amper Meter

6 Stang Massa
1 Input Power
Tanggal

A ENGGINE

Selenoid
Bulan

  

  

  

  

  

  

  

  

  
  

  
 

 
24 25
21 22 23
13 14 15 16 17 18 19 20
10 11 12
9
8
7
6
5
4
3
2
1
30 31
27 28 29
26

REKOMENDASI
Dengan hasil pengecekan tersebut diatas maka memberikan kesimpulan bahwa alat :Layak / Tidak Layak Pakai

Catatan : ..........................................................................................................................................................................................................................
...........................................................................................................................................................................................................................
Cirebon , ...........................2017
Mengetahui Diperiksa Diperiksa

( ................................. ) ( ................................. ) ( ................................. )


Peralatan QHSE Operator
Tahun 2017 PT Adhi Karya (Persero) Tbk
Divisi Konstruksi III
KARTU CEK LIS
ALAT TRAVO LAS

Jenis Alat : Travo Las


No Kode Alat :
No Kode DK :
Merk Alat/Mesin :
Type Alat/Mesin :
No Seri Alat/Mesin :
Kapasitas Alat/Mesin :
Status : Baik

Status :

                                      

Kampas Kopling

   Kampas Kopling
Kampas Kopling
þ Oke
2 Kabel Elektroda

5 Stang Elektroda

ý Tidak (cek ulang)


3 Babel Massa

4 Amper Meter

6 Stang Massa
1 Input Power
Tanggal

A ENGGINE

Selenoid
Bulan

  

  

  

  

  

  

  

  

  
  

  
 

 
24 25
21 22 23
13 14 15 16 17 18 19 20
10 11 12
9
8
7
6
5
4
3
2
1
30 31
27 28 29
26

REKOMENDASI
Dengan hasil pengecekan tersebut diatas maka memberikan kesimpulan bahwa alat :Layak / Tidak Layak Pakai

Catatan : ..........................................................................................................................................................................................................................
...........................................................................................................................................................................................................................
Cirebon , ...........................2017
Mengetahui Diperiksa Diperiksa

( ................................. ) ( ................................. ) ( ................................. )


Peralatan QHSE Operator
Tahun 2017 PT Adhi Karya (Persero) Tbk
Divisi Konstruksi III
KARTU CEK LIS
ALAT JACK HUMMER

Jenis Alat : Jack Hummer


No Kode Alat :
No Kode DK :
Merk Alat/Mesin :
Type Alat/Mesin : TPB 60
No Seri Alat/Mesin :
Kapasitas Alat/Mesin :
Status : Baik

Status :

                                    
Minyak Pelumas

Kampas Kopling

Kampas Kopling

Kampas Kopling
þ Oke
selang Udara

ý Tidak (cek ulang)


Tanggal

Mata Pisau
ENGGINE

Selenoid
Bulan

A
1

3
2

  

  

  

  

  

  

  

  

  

  
  

  
 

 
24 25
21 22 23
13 14 15 16 17 18 19 20
10 11 12
9
8
7
6
5
4
3
2
1
30 31
27 28 29
26

REKOMENDASI
Dengan hasil pengecekan tersebut diatas maka memberikan kesimpulan bahwa alat :Layak / Tidak Layak Pakai

Catatan : ..........................................................................................................................................................................................................................
...........................................................................................................................................................................................................................
Cirebon , ...........................2017
Mengetahui Diperiksa Diperiksa

( ................................. ) ( ................................. ) ( ................................. )


Peralatan QHSE Operator
Tahun 2017 PT Adhi Karya (Persero) Tbk
Divisi Konstruksi III
KARTU CEK LIS
ALAT JACK HUMMER

Jenis Alat : Jack Hummer


No Kode Alat :
No Kode DK :
Merk Alat/Mesin :
Type Alat/Mesin : 60 LB
No Seri Alat/Mesin :
Kapasitas Alat/Mesin :
Status : Rusak

Status :

                                    
Minyak Pelumas

Kampas Kopling

Kampas Kopling

Kampas Kopling
þ Oke
selang Udara

ý Tidak (cek ulang)


Tanggal

Mata Pisau
ENGGINE

Selenoid
Bulan

A
1

3
2

  

  

  

  

  

  

  

  

  

  
  

  
 

 
24 25
21 22 23
13 14 15 16 17 18 19 20
10 11 12
9
8
7
6
5
4
3
2
1
30 31
27 28 29
26

REKOMENDASI
Dengan hasil pengecekan tersebut diatas maka memberikan kesimpulan bahwa alat :Layak / Tidak Layak Pakai

Catatan : ..........................................................................................................................................................................................................................
...........................................................................................................................................................................................................................
Cirebon , ...........................2017
Mengetahui Diperiksa Diperiksa

( ................................. ) ( ................................. ) ( ................................. )


Peralatan QHSE Operator
Tahun 2017 PT Adhi Karya (Persero) Tbk
Divisi Konstruksi III
KARTU CEK LIS
ALAT JACK HUMMER

Jenis Alat : Jack Hummer


No Kode Alat :
No Kode DK :
Merk Alat/Mesin :
Type Alat/Mesin : 60 LB
No Seri Alat/Mesin :
Kapasitas Alat/Mesin :
Status : Rusak

Status :

                                      
3 Minyak Pelumas

Kampas Kopling

   Kampas Kopling
Kampas Kopling
þ Oke
2 selang Udara

ý Tidak (cek ulang)


Tanggal

1 Mata Pisau
A ENGGINE

Selenoid
Bulan

  

  

  

  

  

  

  

  

  
  

  
 

 
24 25
21 22 23
13 14 15 16 17 18 19 20
10 11 12
9
8
7
6
5
4
3
2
1
30 31
27 28 29
26

REKOMENDASI
Dengan hasil pengecekan tersebut diatas maka memberikan kesimpulan bahwa alat :Layak / Tidak Layak Pakai

Catatan : ..........................................................................................................................................................................................................................
...........................................................................................................................................................................................................................
Cirebon , ...........................2017
Mengetahui Diperiksa Diperiksa

( ................................. ) ( ................................. ) ( ................................. )


Peralatan QHSE Operator
Tahun 2017 PT Adhi Karya (Persero) Tbk
Divisi Konstruksi III
KARTU CEK LIS
ALAT JACK HUMMER

Jenis Alat : Jack Hummer


No Kode Alat :
No Kode DK :
Merk Alat/Mesin :
Type Alat/Mesin : 7G225
No Seri Alat/Mesin :
Kapasitas Alat/Mesin :
Status : Rusak

Status :

                                      
3 Minyak Pelumas

Kampas Kopling

   Kampas Kopling
Kampas Kopling
þ Oke
2 selang Udara

ý Tidak (cek ulang)


Tanggal

1 Mata Pisau
A ENGGINE

Selenoid
Bulan

  

  

  

  

  

  

  

  

  
  

  
 

 
24 25
21 22 23
13 14 15 16 17 18 19 20
10 11 12
9
8
7
6
5
4
3
2
1
30 31
27 28 29
26

REKOMENDASI
Dengan hasil pengecekan tersebut diatas maka memberikan kesimpulan bahwa alat :Layak / Tidak Layak Pakai

Catatan : ..........................................................................................................................................................................................................................
...........................................................................................................................................................................................................................
Cirebon , ...........................2017
Mengetahui Diperiksa Diperiksa

( ................................. ) ( ................................. ) ( ................................. )


Peralatan QHSE Operator
Tahun 2017 PT Adhi Karya (Persero) Tbk
Divisi Konstruksi III
KARTU CEK LIS
ALAT JACK HUMMER

Jenis Alat : Jack Hummer


No Kode Alat :
No Kode DK :
Merk Alat/Mesin : Toku
Type Alat/Mesin : TPB 60
No Seri Alat/Mesin :
Kapasitas Alat/Mesin :
Status : Rusak

Status :

                                      
3 Minyak Pelumas

Kampas Kopling

   Kampas Kopling
Kampas Kopling
þ Oke
2 selang Udara

ý Tidak (cek ulang)


Tanggal

1 Mata Pisau
A ENGGINE

Selenoid
Bulan

  

  

  

  

  

  

  

  

  
  

  
 

 
24 25
21 22 23
13 14 15 16 17 18 19 20
10 11 12
9
8
7
6
5
4
3
2
1
30 31
27 28 29
26

REKOMENDASI
Dengan hasil pengecekan tersebut diatas maka memberikan kesimpulan bahwa alat :Layak / Tidak Layak Pakai

Catatan : ..........................................................................................................................................................................................................................
...........................................................................................................................................................................................................................
Cirebon , ...........................2017
Mengetahui Diperiksa Diperiksa

( ................................. ) ( ................................. ) ( ................................. )


Peralatan QHSE Operator
Tahun 2017 PT Adhi Karya (Persero) Tbk
Divisi Konstruksi III
KARTU CEK LIS
ALAT CUTTER

Jenis Alat : Cutter


No Kode Alat :
No Kode DK :
Merk Alat/Mesin : Vipac/Honda
Type Alat/Mesin : GX-390E
No Seri Alat/Mesin :
Kapasitas Alat/Mesin : 13HP/ø14
Status : Baik
2 Air Pendingin Mata Pisau

Status :

                                      
3 Minyak Pelumas

Kampas Kopling

   Kampas Kopling
Kampas Kopling
þ Oke
ý Tidak (cek ulang)
Tanggal

1 Mata Pisau
A ENGGINE

Selenoid
Bulan

  

  

  

  

  

  

  

  

  
  

  
 

 
24 25
21 22 23
13 14 15 16 17 18 19 20
10 11 12
9
8
7
6
5
4
3
2
1
30 31
27 28 29
26

REKOMENDASI
Dengan hasil pengecekan tersebut diatas maka memberikan kesimpulan bahwa alat :Layak / Tidak Layak Pakai

Catatan : ..........................................................................................................................................................................................................................
...........................................................................................................................................................................................................................
Cirebon , ...........................2017
Mengetahui Diperiksa Diperiksa

( ................................. ) ( ................................. ) ( ................................. )


Peralatan QHSE Operator
Tahun 2017 PT Adhi Karya (Persero) Tbk
Divisi Konstruksi III
KARTU CEK LIS
ALAT ASPHALT FINISHER

Jenis Alat : Asphalt Finisher


No Kode Alat : E.07.0591.B.09
No Kode DK : AF 08
Merk Alat/Mesin : Nigata/Isuzu
Type Alat/Mesin : DM.4.0/4J B1.PA-13
No Seri Alat/Mesin : DM.W.0053/738830
Kapasitas Alat/Mesin : 40 Ton/H /70HP
Status : Baik

Ampere Meter                                    

Kopling Maju Mundur


Water Temperatur Gauge

Engine Pressure Gauge

Mundur
ELECTRIC SYSTEM
Status :

Water Temperatur

Kopling

Kampas Kopling

Kampas Kopling

Kampas Kopling
þ Oke
Injection Pump

House Hydrolic
Tutup Radiator

Pump Hydrolic

4  Motor Hydrolic
ý

Seal Cylinder
Tidak (cek ulang)

4   Fuel Indikator

Maju
Hours Meter

Transmision
Tanggal

Hand Break

Roller
C HYDROLIC
ENGGINE

Fuel Fiter

Van Belt
Kenalpot
Oil Filter

Radiator
Bulan

Kampas

Kampas
Air Filter

Handel
Battery
Stik Oil

Lampu
Break

RPM

Track
D   DLL
DLL
10  
10

12
11

1  

2  

3  

5  

9  

1  

2  

3  

2  

3  

4  

5  
8  
A


5
1

6
3

B
2

8
9
24 25
21 22 23
10 11 12 13 14 15 16 17 18 19 20
9
8
7
6
5
4
3
2
1
27 28 29 30 31
26

REKOMENDASI
Dengan hasil pengecekan tersebut diatas maka memberikan kesimpulan bahwa alat :Layak / Tidak Layak Pakai

Catatan : ..........................................................................................................................................................................................................................
...........................................................................................................................................................................................................................
Cirebon , ...........................2017
Mengetahui Diperiksa Diperiksa

( ................................. ) ( ................................. ) ( ................................. )


Peralatan QHSE Operator
Tahun 2017 PT Adhi Karya (Persero) Tbk
Divisi Konstruksi III
KARTU CEK LIS
ALAT ASPHALT FINISHER

Jenis Alat : Asphalt Finisher


No Kode Alat :
No Kode DK :
Merk Alat/Mesin : Mitshubishi/Catterpilar
Type Alat/Mesin : MF 61 E/
No Seri Alat/Mesin : A 5P08827
Kapasitas Alat/Mesin :
Status : Baik

Ampere Meter                                    

Kopling Maju Mundur


Water Temperatur Gauge

Engine Pressure Gauge

Mundur
ELECTRIC SYSTEM
Status :

Water Temperatur

Kopling

Kampas Kopling

Kampas Kopling

Kampas Kopling
þ Oke
Injection Pump

House Hydrolic
Tutup Radiator

Pump Hydrolic

4  Motor Hydrolic
ý

Seal Cylinder
Tidak (cek ulang)

4   Fuel Indikator

Maju
Hours Meter

Transmision
Tanggal

Hand Break

Roller
C HYDROLIC
ENGGINE

Fuel Fiter

Van Belt
Kenalpot
Oil Filter

Radiator
Bulan

Kampas

Kampas
Air Filter

Handel
Battery
Stik Oil

Lampu
Break

RPM

Track
D   DLL
DLL
10  
10

12
11

1  

2  

3  

5  

9  

1  

2  

3  

2  

3  

4  

5  
8  
A


5
1

6
3

B
2

8
9
24 25
21 22 23
10 11 12 13 14 15 16 17 18 19 20
9
8
7
6
5
4
3
2
1
27 28 29 30 31
26

REKOMENDASI
Dengan hasil pengecekan tersebut diatas maka memberikan kesimpulan bahwa alat :Layak / Tidak Layak Pakai

Catatan : ..........................................................................................................................................................................................................................
...........................................................................................................................................................................................................................
Cirebon , ...........................2017
Mengetahui Diperiksa Diperiksa

( ................................. ) ( ................................. ) ( ................................. )


Peralatan QHSE Operator
Tahun 2017 PT Adhi Karya (Persero) Tbk
Divisi Konstruksi III
KARTU CEK LIS
ALAT ASPHALT FINISHER

Jenis Alat : Asphalt Finisher


No Kode Alat : E.07.0591.B.10
No Kode DK : AF 09
Merk Alat/Mesin : Sumitomo/Mitsubishi
Type Alat/Mesin : HA.40 W 5/4 DR 5
No Seri Alat/Mesin :
Kapasitas Alat/Mesin : 40 Ton/H/70 HP
Status : Baik

Ampere Meter                                    

Kopling Maju Mundur


Water Temperatur Gauge

Engine Pressure Gauge

Mundur
ELECTRIC SYSTEM
Status :

Water Temperatur

Kopling

Kampas Kopling

Kampas Kopling

Kampas Kopling
þ Oke
Injection Pump

House Hydrolic
Tutup Radiator

Pump Hydrolic

4  Motor Hydrolic
ý

Seal Cylinder
Tidak (cek ulang)

4   Fuel Indikator

Maju
Hours Meter

Transmision
Tanggal

Hand Break

Roller
C HYDROLIC
ENGGINE

Fuel Fiter

Van Belt
Kenalpot
Oil Filter

Radiator
Bulan

Kampas

Kampas
Air Filter

Handel
Battery
Stik Oil

Lampu
Break

RPM

Track
D   DLL
DLL
10  
10

12
11

1  

2  

3  

5  

9  

1  

2  

3  

2  

3  

4  

5  
8  
A


5
1

6
3

B
2

8
9
24 25
13 14 15 16 17 18 19 20 21 22 23
10 11 12
9
8
7
6
5
4
3
2
1
30 31
27 28 29
26

REKOMENDASI
Dengan hasil pengecekan tersebut diatas maka memberikan kesimpulan bahwa alat :Layak / Tidak Layak Pakai

Catatan : ..........................................................................................................................................................................................................................
...........................................................................................................................................................................................................................
Cirebon , ...........................2017
Mengetahui Diperiksa Diperiksa

( ................................. ) ( ................................. ) ( ................................. )


Peralatan QHSE Operator
Tahun 2017 PT Adhi Karya (Perser
Divisi Konstruksi I
KARTU CEK LIS
ALAT PENUMATIK TIRE ROLLER

Jenis Alat : PTR


No Kode Alat : D.17.1003.R.03
No Kode DK : TR 03
Merk Alat/Mesin : Sakai/isuzu
Type Alat/Mesin : TS 200/6 BDI
No Seri Alat/Mesin : TTS3-10699
Kapasitas Alat/Mesin : 8-12 Ton/120 HP
Status : Baik

Altenator                                    

Indikator Water Temperatur


ELECTRIC SYSTEM

Join Pump Hydrolic


Filter Oil Hydrolic
Indikator Ampere

Join Kopling

JoinKopling

Kopling

Kampas Kopling
Kampas Kopling
Injection Pump

House Hydrolic
Tutup Radiator

Pump Hydrolic

Seal Cylinder
House Meter
Motor Stater
Tanggal

Break
C HYDROLIC
ENGGINE

TRANMISI
Box Fuse
Fuel Fiter

Gear Box
Van Belt

Kenalpot

Selenoid
Oil Filter

Radiator

Kampas

Kampas
Bulan

Kampas
Air Filter

Klakson
Battery
Stik Oil

Lampu
Break

Hand
Yuke
RPM

Bolt
D  
10

5  

8  

9  

1  

2  

3  

4  

5  
1  

2  

3  

4  

1  

2  

3  

4  

5  
A


1

B
7
3
2

8
9
24 25
21 22 23
13 14 15 16 17 18 19 20
10 11 12
9
8
7
6
5
4
3
2
1
30 31
27 28 29
26

REKOMENDASI
Dengan hasil pengecekan tersebut diatas maka memberikan kesimpulan bahwa alat :Layak / Tidak Layak Pakai

Catatan : ..........................................................................................................................................................................................................................
...........................................................................................................................................................................................................................
Cirebon , ...........................2017
Mengetahui Diperiksa Diperiksa

( ................................. ) ( ................................. ) ( ................................. )


Peralatan QHSE Operator
Tahun 2017 PT Adhi Karya (Perser
Divisi Konstruksi I
KARTU CEK LIS
ALAT PENUMATIK TIRE ROLLER

Jenis Alat : PTR


No Kode Alat : D.17.0804.R.01
No Kode DK : TR 11
Merk Alat/Mesin : Sakai/isuzu
Type Alat/Mesin : TS 200/6 BDI L J-01
No Seri Alat/Mesin : TTS3-10519
Kapasitas Alat/Mesin : 8-12 Ton/120 HP
Status : Baik

Altenator                                    

Indikator Water Temperatur


ELECTRIC SYSTEM

Join Pump Hydrolic


Filter Oil Hydrolic
Indikator Ampere

Join Kopling

JoinKopling

Kopling

Kampas Kopling
Kampas Kopling
Injection Pump

House Hydrolic
Tutup Radiator

Pump Hydrolic

Seal Cylinder
House Meter
Motor Stater
Tanggal

Break
C HYDROLIC
ENGGINE

TRANMISI
Box Fuse
Fuel Fiter

Gear Box
Van Belt

Selenoid
Kenalpot
Oil Filter

Radiator

Kampas

Kampas
Bulan

Kampas
Air Filter

Klakson
Battery
Stik Oil

Lampu
Break

Hand
Yuke
RPM

Bolt
D  
10

5  

8  

9  

1  

2  

3  

4  

5  
1  

2  

3  

4  

1  

2  

3  

4  

5  
A


5
1

B
3

7
2

8
9
24 25
21 22 23
13 14 15 16 17 18 19 20
10 11 12
9
8
7
6
5
4
3
2
1
30 31
27 28 29
26

REKOMENDASI
Dengan hasil pengecekan tersebut diatas maka memberikan kesimpulan bahwa alat :Layak / Tidak Layak Pakai

Catatan : ..........................................................................................................................................................................................................................
...........................................................................................................................................................................................................................
Cirebon , ...........................2017
Mengetahui Diperiksa Diperiksa

( ................................. ) ( ................................. ) ( ................................. )


Peralatan QHSE Operator
Tahun 2017 PT Adhi Karya (Perser
Divisi Konstruksi I
KARTU CEK LIS
ALAT PENUMATIK TIRE ROLLER

Jenis Alat : PTR


No Kode Alat : -
No Kode DK : -
Merk Alat/Mesin : Sakai/isuzu
Type Alat/Mesin : TS 205/
No Seri Alat/Mesin : 6TS9-10194/6BG1-361349
Kapasitas Alat/Mesin : 10,5Ton
Status : Baik

Altenator                                    

Indikator Water Temperatur


ELECTRIC SYSTEM

Join Pump Hydrolic


Filter Oil Hydrolic
Indikator Ampere

Join Kopling

JoinKopling

Kopling

Kampas Kopling
Kampas Kopling
Injection Pump

House Hydrolic
Tutup Radiator

Pump Hydrolic

Seal Cylinder
House Meter
Motor Stater
Tanggal

Break
C HYDROLIC
ENGGINE

TRANMISI
Box Fuse
Fuel Fiter

Gear Box
Van Belt

Selenoid
Kenalpot
Oil Filter

Radiator

Kampas

Kampas
Bulan

Kampas
Air Filter

Klakson
Battery
Stik Oil

Lampu
Break

Hand
Yuke
RPM

Bolt
D  
10

5  

8  

9  

1  

2  

3  

4  

5  
1  

2  

3  

4  

1  

2  

3  

4  

5  
A


5
1

B
3

7
2

8
9
24 25
21 22 23
13 14 15 16 17 18 19 20
10 11 12
9
8
7
6
5
4
3
2
1
30 31
27 28 29
26

REKOMENDASI
Dengan hasil pengecekan tersebut diatas maka memberikan kesimpulan bahwa alat :Layak / Tidak Layak Pakai

Catatan : ..........................................................................................................................................................................................................................
...........................................................................................................................................................................................................................
Cirebon , ...........................2017
Mengetahui Diperiksa Diperiksa

( ................................. ) ( ................................. ) ( ................................. )


Peralatan QHSE Operator
Tahun 2017 PT Adhi Karya (Perser
Divisi Konstruksi I
KARTU CEK LIS
ALAT PENUMATIK TIRE ROLLER

Jenis Alat : PTR


No Kode Alat : -
No Kode DK : -
Merk Alat/Mesin : Sakai/isuzu
Type Alat/Mesin : TS 205/
No Seri Alat/Mesin : 6TS9-10196/6BG1-361356
Kapasitas Alat/Mesin : 10,5Ton
Status : Baik

Altenator                                    

Indikator Water Temperatur


ELECTRIC SYSTEM

Join Pump Hydrolic


Filter Oil Hydrolic
Indikator Ampere

Join Kopling

JoinKopling

Kopling

Kampas Kopling
Kampas Kopling
Injection Pump

House Hydrolic
Tutup Radiator

Pump Hydrolic

Seal Cylinder
House Meter
Motor Stater
Tanggal

Break
C HYDROLIC
ENGGINE

TRANMISI
Box Fuse
Fuel Fiter

Gear Box
Van Belt

Selenoid
Kenalpot
Oil Filter

Radiator

Kampas

Kampas
Bulan

Kampas
Air Filter

Klakson
Battery
Stik Oil

Lampu
Break

Hand
Yuke
RPM

Bolt
D  
10

5  

8  

9  

1  

2  

3  

4  

5  
1  

2  

3  

4  

1  

2  

3  

4  

5  
A


5
1

B
3

7
2

8
9
24 25
13 14 15 16 17 18 19 20 21 22 23
10 11 12
9
8
7
6
5
4
3
2
1
27 28 29 30 31
26

REKOMENDASI
Dengan hasil pengecekan tersebut diatas maka memberikan kesimpulan bahwa alat :Layak / Tidak Layak Pakai

Catatan : ..........................................................................................................................................................................................................................
...........................................................................................................................................................................................................................
Cirebon , ...........................2017
Mengetahui Diperiksa Diperiksa

( ................................. ) ( ................................. ) ( ................................. )


Peralatan QHSE Operator
PT Adhi Karya (Persero) Tbk
Divisi Konstruksi III

Status :

Kampas Kopling
þ Oke
ý Tidak (cek ulang)

Selenoid
PT Adhi Karya (Persero) Tbk
Divisi Konstruksi III

Status :

Kampas Kopling
þ Oke
ý Tidak (cek ulang)

Selenoid
PT Adhi Karya (Persero) Tbk
Divisi Konstruksi III

Status :

Kampas Kopling
þ Oke
ý Tidak (cek ulang)

Selenoid
PT Adhi Karya (Persero) Tbk
Divisi Konstruksi III

Status :

Kampas Kopling
þ Oke
ý Tidak (cek ulang)

Selenoid
Tahun 2017 PT Adhi Karya (Persero) Tbk
Divisi Konstruksi III
KARTU CEK LIS
ALAT GENSET

Jenis Alat : Genset


No Kode Alat : -
No Kode DK : -
Merk Alat/Mesin : AVK/Mitsubishi
Type Alat/Mesin : 6 D 40
No Seri Alat/Mesin : 261465
Kapasitas Alat/Mesin : 325 KVA
Status : Baik

Altenator                                    

Indikator Water Temperatur


ELECTRIC SYSTEM
Status :

Kampas Kopling

Kampas Kopling

Kampas Kopling
þ Oke
Injection Pump

4   Dinamo Ampere


Tutup Radiator

ý Tidak (cek ulang)

Motor Stater
Tanggal

ENGGINE

Fuel Fiter

Selenoid
Kenalpot
Oil Filter

Radiator
Bulan

Air Filter

Battery
Stik Oil

1  

2  

3  

5  
A

5
1

B
3

7
2

  

  

  

  
 

 
24 25
21 22 23
13 14 15 16 17 18 19 20
10 11 12
9
8
7
6
5
4
3
2
1
30 31
27 28 29
26

REKOMENDASI
Dengan hasil pengecekan tersebut diatas maka memberikan kesimpulan bahwa alat :Layak / Tidak Layak Pakai

Catatan : ..........................................................................................................................................................................................................................
...........................................................................................................................................................................................................................
Cirebon , ...........................2017
Mengetahui Diperiksa Diperiksa

( ................................. ) ( ................................. ) ( ................................. )


Peralatan QHSE Operator
Tahun 2017 PT Adhi Karya (Per
Divisi Konstruk
KARTU CEK LIS
ALAT STONE CRUSHER

Jenis Alat : Stone Crusher


No Kode Alat : -
No Kode DK : SC 01
Merk Alat/Mesin : Kurimoto dan Shanbo
Type Alat/Mesin : -
No Seri Alat/Mesin : M 84-537
Kapasitas Alat/Mesin : -
Status : Baik

4  Periksa V-Belt Motor                                     


Periksa Pelumas Bearing As Secreen
4 Periksa Sambungan Belt Conveyor
2 Periksa Feeder / Fibro dan Kabel

Periksa Motor Screen dan V-Belt


3 Periksa dan Lumasi Rantai Roll
2 Periksa Roll-Roll Belt Conveyor

3  Periksa Screen dan Kebocoran

Periksa Panel - Panel Control


3 Periksa Contaktor Over Load

Periksa Panel - Panel Control


B BAGIAN BELT CONVEYOR

D  BAGIAN PANEL CONTROL


5 Periksa Oli Motor Gear Box
1 Periksa Bearing Motor Roll

Periksa Dwicth ON / OFF


 1  Periksa Dwitch Breaker
1 Periksa Pintu Cold Bin
A BAGIAN COLD BIN

C BAGIAN SCREEN

Kampas Kopling

Kampas Kopling

Kampas Kopling
Dinamo Ampere
Tanggal

Selenoid
Bulan


1

4
  

  

  
2

  
 

 
24 25
21 22 23
13 14 15 16 17 18 19 20
10 11 12
9
8
7
6
5
4
3
2
1
30 31
27 28 29
26

REKOMENDASI
Dengan hasil pengecekan tersebut diatas maka memberikan kesimpulan bahwa alat :Layak / Tidak Layak Pakai

Catatan : ..........................................................................................................................................................................................................................
...........................................................................................................................................................................................................................
Cirebon , ...........................2017
Mengetahui Diperiksa Diperiksa

( ................................. ) ( ................................. ) ( ................................. )


Peralatan QHSE Operator
PT Adhi Karya (Persero) Tbk
Divisi Konstruksi III
ARTU CEK LIS
T STONE CRUSHER

Status :
þ Oke
ý Tidak (cek ulang)

Selenoid
 
26
27 28 29 30 31 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 Tanggal

Status
Bulan
Jenis Alat

Tahun 2017
Tahun 2017

No Kode DK

A BAGIAN COLD BIN


No Kode Alat

Type Alat/Mesin
Merk Alat/Mesin

REKOMENDASI
1 Periksa Buka Tutup Pintu Cold Bin
No Seri Alat/Mesin
Kapasitas Alat/Mesin

2 Periksa Feeder / Vibro dan Kabel

Peralatan
:
:
:
:
:
:
:
:

Mengetahui
B BAGIAN BELT CONVEYOR

( ................................. )
1 Periksa Bearing Motor Roll
Baik
Bukaka

2 Periksa Rantai Penggerak Motor Roll


60/Ton/H

3 Periksa Sambungan Belt Conveyor


BAMP -800-SA

4 Periksa Oli Motor Gear Box


C BAGIAN SCREEN
1
Aspalt Mixing Plant (AMP)

Periksa Motor Screen dan V-Belt


Periksa Isi Pelumas Bearing As Screen
2

3  Periksa Screen dan Kebocoran

4  Periksa V-Belt Motor                                     

D  BAGIAN PANEL CONTROL

QHSE
Diperiksa
1  
Periksa Switch Breaker
Periksa Swicth ON / OFF

( ................................. )
Dinamo Ampere
3 Periksa Contaktor Over Load
Periksa Panel - Panel Control

4                     
Periksa Panel - Panel Control
BAGIAN
BAGIAN DRAYER DRAYER
E                                     
 
BAGIAN
1    Motor Gear Box dan Rantai Penggerak
DRAYER
                                  
BAGIANDrive
   Periksa DRAYER Gear dan Ring Gear
2                                    
Periksa
BAGIANThrus DRAYER Rloller Drayer
3                                   

Dengan hasil pengecekan tersebut diatas maka memberikan kesimpulan bahwa alat :Layak / Tidak Layak Pakai
Periksa
BAGIANRing DRAYER Drayer

4                                    
Periksa
BAGIANTermo DRAYER Cople
5                                    
Periksa Oli Motor Gear Box
KARTU CEK LIS

6                      
Periksa Panel - Panel Control
BAGIAN
BAGIAN DRAYER ELEVATOR
F                                     

Operator
Diperiksa
 
BAGIANRantai DRAYER Hot Elevator
ALAT ASPALT MIXING PLANT ( AMP )

1    Periksa
                                  

( ................................. )
Periksa Oli Motor Gear Box

                        
Periksa Panel - Panel Control
Kampas Kopling
BAGIAN
BAGIAN DRAYER
HOT BIN

...........................................................................................................................................................................................................................
G                                     

Cirebon , ...........................2017
Catatan : ..........................................................................................................................................................................................................................
 
BAGIANScale
1    Periksa DRAYER Timbangan Material
                                  
                    
Periksa Panel - Panel Control
Kampas
BAGIAN
BAGIAN Kopling
DRAYER
MIXER
H                                     
 
BAGIANLanatai
1    Periksa
                    DRAYER Mixer
                                   
Periksa Panel - Panel Control
Periksa
BAGIANOli Motor Gear Box
DRAYER

                                      
                    
Periksa Panel - Panel Control
Periksa
BAGIAN Gigi
DRAYERPenggerak
3                     
                                  
Periksa Panel - Panel Control
KARTU CEK LIS
ALAT STONE CRUSHER

Jenis Alat : Aspalt Mixing Plant (AMP)


No Kode Alat :
No Kode DK :
Merk Alat/Mesin : AZP
Type Alat/Mesin : AZP 1000
No Seri Alat/Mesin : A160402L10
Kapasitas Alat/Mesin : 60-80/Ton/H
Status : Baik

4  Periksa V-Belt Motor                                     


Periksa Pelumas Bearing As Secreen
4 Periksa Sambungan Belt Conveyor
2 Periksa Feeder / Fibro dan Kabel

Periksa Motor Screen dan V-Belt


3 Periksa dan Lumasi Rantai Roll
2 Periksa Roll-Roll Belt Conveyor

3  Periksa Screen dan Kebocoran

Periksa Panel - Panel Control


3 Periksa Contaktor Over Load

Periksa Panel - Panel Control


B BAGIAN BELT CONVEYOR

D  BAGIAN PANEL CONTROL


1 Periksa Bearing Motor Roll

Periksa Dwicth ON / OFF


 1  Periksa Dwitch Breaker
1 Periksa Pintu Cold Bin
A BAGIAN COLD BIN

C BAGIAN SCREEN

Kampas Kopling
Dinamo Ampere
Tanggal

Bulan


1

4
  

  

  

  
2

 
1 1 1 1 1 1 1 1 1 1 2 2 2 2 2 2
0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5
1 2 3 4 5 6 7 8 9
2 2 2 3 3
7 8 9 0 1
2
6

REKOMENDASI
Dengan hasil pengecekan tersebut diatas maka memberikan kesimpulan bahwa alat :Layak / Tidak Layak Pakai

Catatan : ..........................................................................................................................................................................................................................
...........................................................................................................................................................................................................................
Cirebon , ...........................2017
Mengetahui Diperiksa Diperiksa

( ................................. ) ( ................................. ) ( ................................. )


Peralatan QHSE Operator
TU CEK LIS
MIXING PLANT ( AMP )

Periksa
BAGIANGigi DRAYERPenggerak
3                     
                                  
Periksa Panel - Panel Control
Kampas Kopling
BAGIAN
BAGIAN DRAYER
AIR COMPRESOR
                              
                    
I                                       
Periksa Panel - Panel Control
1 Periksa
BAGIAN Oli Pelumas
DRAYER
                                  
                    
Periksa Panel - Panel Control
2

Divisi Konstruksi III


Divisi Konstruksi III

PT Adhi Karya (Persero) Tbk


PT Adhi Karya (Persero) Tbk

Kampas Kopling

Kampas Kopling
  Selenoid
þ Oke
Status :

ý Tidak (cek ulang)


PT Adhi Karya (Persero) Tbk
Divisi Konstruksi III
TU CEK LIS
TONE CRUSHER

Status :

Kampas Kopling

Kampas Kopling
þ Oke
ý Tidak (cek ulang)

Selenoid
 

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