DUMP TRUCK INSPECTION FORM

Doc. No. Rev. No.

QC-HSE
ATTACHMENT 4
HSE-FF-L.4 D
HSE Date : Page 1 of 1

PEMILIK / COMPANY TAHUN PEMBUATAN /

YEAR MANUFACTURE
MODEL TANGGAL DIPERIKSA / INSPECTION
DATE

POL.NUMBER DRIVER

PABRIK / MANUFACTURE

KONDISI / KETERANGAN /
ASPEK YANG DIPERIKSA/ASPECT TO BE CHECK
CONDITION REMARKS
UMUM/ Kondisi fisik secara umum / Condition physic in general
GENERAL Rangka & Chasis (Karat / Rusak) / Chasis (Corotion / Broken)
Roda / Ban kanan-kiri / Condition Tier (Right / Left)
Mesin (kotor, ada oli, dll / Does Condition Machine Dirty
Knalpot (Diberi Peredam / Diberi Pembalut ?) / Does arrestor has cap
Klaxon / Does Horn working properly
Cairan hidraulic Bocor ? / Does Hydrolic Leak?
Rem / Does Brake work properly
Tutup Tangki BBM / Does cap gasoline appear
KABIN / Pintu (bisa menutup? ada pegangan ?) / Does door can be close and have handle ?
CABIN Lampu penerangan / Does dashboard lamp work
Jendela dan Kaca Jendela (ada yang pecah ?) / Does window and window glass in good
condition?
Kotak P3K / Does first aid box inside?
Pen ha us air hujan (wiper) / Does water in wiper tank full?
Alat Pemadam Api Ringan / Does Fire Extinguisher inside ?
LAMPU/ Lampu Besar / Does infront lamp work
LAMP Lampu Jalan
Lampu Kecil Depan
Lampu Belakang / Does back lamp work
Lampu Rem / Does Brake Lamp Work
Lampu Sign Kanan / Does Right Sign Lamp Work
Lampu Sign Kiri / Does Left Sign Lamp Work
Lampu Mundur / Does Reverse Lamp Work
BAK Hidraulic baik ? / Does hydraulic leak
Karat / Rusak / Does it corotion / broken
Pintu Belakang (Baik / Macet ) / Does back door in good condition
REKOMENDASI / RECOMMENDATION
:………………………………………………………………………………………………………………………..
KESIMPULAN / CONCLUSION
:………………………………………………………………………………………………………………………..

:………………………………………………………………………………………………………………………..

Mengetahui / Acknowledge Prepared by :

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 (………………………) (………………………)
HSE Coordinator Inspector

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