No.

: FRM-SD-034-01
FORM CHECKLIST PEMERIKSAAN Form
Revisi : 0.0
EHSC-SUST DEPT
Self-Contained Breathing Apparatus (SCBA) Hal : 1 dari 1

PERIODE : MANUFAKTUR :
NO. SCBA : KAPASITAS :
LOKASI : S/N CYLINDER :

KEADAAN
NO GAMBAR PERALATAN BAGIAN YANG DIPERIKSA KETERANGAN
BAIK TIDAK
1 1 Full Face Mask
2 Demand Valve
3 Air Cylinder Valve
4 High Pressure Hose
5 Backboard
6 Alarming Whistle
7 Pressure Gauge
8 Medium Pressure Hose
9 Pressure Reducer
10 Waist Band
11 Belt Buckle
12 Shoulder Strap Fastener
13 Quick Connect Coupling
14 Shoulder Strap
2 15 Over all assembly
16 Headnet and harness anchors
19
17 Regulator connection
18 Rubber Components
17 22
19 Lens
20 Exhalation Valve
16
21 Speaking Diaphragm
21 20
22 Lens Frame Retainer
3 23 Gauge
26
24 Cylinder
25 Valve Hand Wheel
23
26 Burst disc outlet (clear)
24 25 27 Cylinder Pressure (full)
Informasi tambahan
Konstruksi Tanggal Hydro tes Hydro Re-test Tanggal Hydro Re-test Masa Pakai Tanggal Expired
Steel or Aluminum 5 Years Indefinite -
Hoop Wrapped Alum 3 Years 15 Years
Fiberglass Wrapped 3 Years 15 Years
Kevlar Wrapped 3 Years 15 Years
Cover Fiber Wrapped 3 Years 15 Years

Dibuat Oleh, Diketahui Oleh, Disetujui Oleh,

(……………………………….) (………………………………) (……………………………..)

EHS Officer KTU/Ast. Man MM/FM