PT.

SISPUM SARANA GRAHA

TOOL AND EQUIPMENT INSPECTION

Form-I-017

CHAIN BLOCK INSPECTION FORM

Type of Equipment : CARRY-IN CERTIFICATE

Equipment No. : Permit No. :

Manufacturer :
Approved by :
Company User :

Capacity :
Reviewed by :
Month of Inspection :
This form must be completed by the operator and company user before entering the equipment to be operated in the
site project area, and at any time of setting location. All equipment condition must meet to the safety regulation and
TIV SHE Management Plan
Result column: (  ) Yes/Good, Acceptable, ( X ) Not/Bad, Not to use, ( NA ) Not applicable
No Check Item Result Remarks
1 Block Hook
2 Main Block Cover
3 Sieve
4 Main Chain Sling
5 Driver Chain Sling
6 Safety Latch / PIN
7 Locked Out System

INSPECTOR REPORT
Corrective Action Required

Inspection Status:  OK  Not OK  Order for Repair

Contractor
Inspected by Date : Name : Signature :
Position :
Approved by Date : Name : Signature :
Position :

Approved by Date : Name : Signature :

Position :