PT.

SISPUM SARANA GRAHA

TOOL AND EQUIPMENT INSPECTION

BREAKER MACHINE INSPECTION FORM

□ Pile Driver □ Pile Drawer □ Boring Machine □
Earth Auger
Type of Equipment : CARRY-IN CERTIFICATE
Equipment No. : Permit No. :

Manufacturer : Date :

Company User :
Approved by :
Certificate Number :

Month of Inspection : Reviewed by :

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
SHE Management Plan
Result column: (  ) Yes/Good, Acceptable, ( X ) Not/Bad, Not to use, ( NA ) Not applicable
No Check Item Result Remarks

1 Operator has a valid License

2 Equipment has valid certificate
3 Hydraulic system in good condition
4 Traveling system in good condition
5 Diesel breaker system in good condition
6 All electrical system are in good
7 Brake system
8 Operations Handle
9 Back Mirror
10 Lighting Device
11 Alarm System
12 Safety device
13 Boom Hoist Limiting Device
14 Fork horn in good condition
15 Lubrication system
16 Oil leaking
17 Fuel Reservoir
18 Each Side of windows glasses
19 Leveling indicator devices
20 Safe Guards for moving parts
21 Fire Extinguisher
22 Rotator lamp
23
24
 PT. SISPUM SARANA GRAHA

TOOL AND EQUIPMENT INSPECTION

INSPECTOR REPORT
Corrective Action Required

Inspection Status:  OK

 Not OK

 Order for Repair

PT. SISPUM SARANA GRAHA

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

Approved by Date : Name : Signature :

Position :