Laporan Pemeriksaan Tabung angin & Kompresor Report No :

(Air Reciever Tank & Compressor Safety Devices Equipment Rev. Date :18 -1 - 2006
Checklist cum Inspection Report) No.of pages :
First Coming Regular Inspection

Date of Inspection : …………………………………Location : ………………………………….

Type of Equipment : …………………………………….. ID. No. ………………………………
Company :
No Inspection Items G B NA Remarks
1 Tabung angin Kompresor bersertifikat pengujian
Compressor air receiver tested & Certified
2 Pelat identifikasi dari pabrik terpasang & terbaca
Manufacture tag identification provide & be read
3 Katup pengaman terpasang & berfungsi baik
Safety valve installed & functioned
4 Alat pengukur tekanan terpasang & berfungsi baik
Preasure test gauge installed & functioned
5 Selang angin berstandard & Tekanan max.tertulis
Air hose meet to standard & max. preasure marked
6 Pengikat selang mamakai klem plat 2 baut
Hose clamp use plate with 2 nuts
7 Penyambung selang dengan chicago flens
Hose connected use chicago flens
8 Chicago flens terkunci baik & terikat
Chicago flens secured & tie off
9* Nozel selang dilengkapi dead man & berfungsi baik
Hose nozzle connected to dead man & functioned
10* Penyaring udara pernapasan untuk sand blaster
terpasang & berfungsi baik
Air filter devices for blaster breathing asparatus
installed and functioned
11* Peralatan pelindung wajah & badan khusus sandblaster
tersedia & dalam kondisi baik
Specific particullary eye & body protection provided
and in good condition
Untuk Mesin Kompresor / For Compressor engine
1 Mesin kompressor bersertifikat pengujian
Compressor engine tested & certfied
2 Panel-panel instrument / Instruments panels :
a. Indikator tekanan angin / Air preasure indicator
b. Indikator tekanan pelumas / Lubricate preasure indicator
c.Indicator cas bateray / Batteray charge indicator
d. Indikator waktu pakai / Hours indicator
3 Alat penghenti mesin darurat tersedia & berfungsi baik
Engine Emergency Shut Down provided & functioned
4 Perawatan mesin teraratur & tercatat
Regular engine maintenance & recorded
5 Tidak ada kebocoran/tumpahan sistem B.Bakar / pelumasan
No Fuel / lubricate system leak and oil spill
6 Kondisi umum/Kebersihan / General condition/cleanliness Rev

Note : G = Good, B = Bad, NA = Not Applicable * Hanya untuk Pekerjaan Blasting (For Sandblasting Work only)
Recommandations: ……………………………………………………………………………………………………………..
……………………………………………………………………………………………………………………………….
……………………………………………………………………………………………………………………………….
……………………………………………………………………………………………………………………………….
……………………………………………………………………………………………………………………………….

INSPECTED BY, ACKNOWLEDGED BY,

NAME: NAME: NAME:

SIGNATURE SIGNATURE SIGNATURE

HSE Officer Supervisor Responsible
Doc.No-NSB-HSE-F18
SIGNATURE SIGNATURE SIGNATURE
HSE Officer Supervisor Responsible

Doc.No-NSB-HSE-F18
 Laporan Pemeriksaan Tabung angin & Kompresor Report No :
(Air Reciever Tank & Compressor Safety Devices Equipment Rev. Date :
Checklist cum Inspection Report) No.of pages :
First Coming Regular Inspection

Date of Inspection : …………………………………Location : ………………………………….

Type of Equipment : …………………………………….. ID. No. ……………………………… PT. NISCONI
Company :
No Inspection Items G B NA Remarks
1 Tabung angin Kompresor bersertifikat pengujian
Compressor air receiver tested & Certified
2 Pelat identifikasi dari pabrik terpasang & terbaca
Manufacture tag identification provide & be read
3 Katup pengaman terpasang & berfungsi baik
Safety valve installed & functioned
4 Alat pengukur tekanan terpasang & berfungsi baik
Preasure test gauge installed & functioned
5 Selang angin berstandard & Tekanan max.tertulis
Air hose meet to standard & max. preasure marked
6 Pengikat selang mamakai klem plat 2 baut
Hose clamp use plate with 2 nuts
7 Penyambung selang dengan chicago flens
Hose connected use chicago flens
8 Chicago flens terkunci baik & terikat
Chicago flens secured & tie off
9* Nozel selang dilengkapi dead man & berfungsi baik
Hose nozzle connected to dead man & functioned
10* Penyaring udara pernapasan untuk sand blaster
terpasang & berfungsi baik
Air filter devices for blaster breathing asparatus
installed and functioned
11* Peralatan pelindung wajah & badan khusus sandblaster
tersedia & dalam kondisi baik
Specific particullary eye & body protection provided
and in good condition
Untuk Mesin Kompresor / For Compressor engine
1 Mesin kompressor bersertifikat pengujian
Compressor engine tested & certfied
2 Panel-panel instrument / Instruments panels :
a. Indikator tekanan angin / Air preasure indicator
b. Indikator tekanan pelumas / Lubricate preasure indicator
c.Indicator cas bateray / Batteray charge indicator
d. Indikator waktu pakai / Hours indicator
3 Alat penghenti mesin darurat tersedia & berfungsi baik
Engine Emergency Shut Down provided & functioned
4 Perawatan mesin teraratur & tercatat
Regular engine maintenance & recorded
5 Tidak ada kebocoran/tumpahan sistem B.Bakar / pelumasan
No Fuel / lubricate system leak and oil spill
6 Kondisi umum/Kebersihan / General condition/cleanliness

Note : G = Good, B = Bad, NA = Not Applicable * Hanya untuk Pekerjaan Blasting (For Sandblasting Work only)
Recommandations: ……………………………………………………………………………………………………………..
……………………………………………………………………………………………………………………………….
……………………………………………………………………………………………………………………………….
……………………………………………………………………………………………………………………………….
……………………………………………………………………………………………………………………………….

INSPECTED BY, ACKNOWLEDGED BY,

NAME: NAME:

SIGNATURE SIGNATURE
HSE Officer Supervisor Responsible
Doc.No-NSB-HSE-F18
SIGNATURE SIGNATURE
HSE Officer Supervisor Responsible

Doc.No-NSB-HSE-F18