Saudi Binladin Group

TRANSPORT AND HEAVY EQUIPMENT
Document No: SBG‐HSE – 023‐01                                   Revision: 0

Date Modified: 

EQ Type ‫اﻟﻤﻌﺪة‬ ‫ﻧ ع‬ FORK LIFT Date of inspection  ‫اﻟﻔﺤﺺ‬ ‫ﺗﺎر ــﺦ‬

EQ  S.N ‫ﻟﻠﻤﻌﺪة‬  ‫اﻟ ﺴﻠﺴ‬ ‫اﻟﺮﻗﻢ‬  Inspection No ‫اﻟﻔﺤﺺ‬ ‫رﻗﻢ‬
Manufacture Company ‫اﻟﻤﺼﻨﻌﺔ‬ ‫اﻟ ﻛﺔ‬ Company ‫اﻟ ﻛﺔ‬
Equipment No  ‫اﻟﻤﻌﺪة‬ ‫رﻗﻢ‬ Operator Name ‫اﻟﻤﺸﻐﻞ‬ ‫إﺳﻢ‬
EQ TUV NO  ‫اﻟﻤﻌﺪة‬ ‫إﻋﺘﻤﺎد‬ ‫رﻗﻢ‬ Operator TUV NO ‫اﻟﻤﺸﻐﻞ‬ ‫إﻋﺘﻤﺎد‬ ‫رﻗﻢ‬
EQ TUV Exp Date ‫اﻟﻤﻌﺪة‬ ‫إﻋﺘﻤﺎد‬ ‫إﻧﺘﻬﺎء‬ ‫ﺗﺎر ــﺦ‬ OPerator TUV Exp Date ‫ﻟﻠﻤﺸﻐﻞ‬ ‫إﻋﺘﻤﺎد‬  ‫إﻧﺘﻬﺎء‬ ‫ﺗﺎر ــﺦ‬
Comments ‫ﻣﻼﺣﻈﺎت‬ Seatbelt                             ‫اﻷﻣﺎن‬ ‫ﺣﺰام‬
1
N/A No Yes
 ‫واﻟﺨﻠﻔ ﺔ‬ ‫اﻷﻣﺎﻣ ﺔ‬ ‫اﻹﺿﺎءة‬
Comments ‫ﻣﻼﺣﻈﺎت‬
Front & Back Lights 
2
N/A No Yes

Comments ‫ﻣﻼﺣﻈﺎت‬ Revolve Light             ‫اﻟﻤﺨﺎﻃﺮ‬ ‫إﺿﺎءة‬

3
N/A No Yes

Comments ‫ﻣﻼﺣﻈﺎت‬ Reverse Alarm        ‫ﻟﻠﺨﻠﻒ‬ ‫اﻟﺮﺟ ع‬ ‫إﻧﺬار‬

4
N/A No Yes

Comments ‫ﻣﻼﺣﻈﺎت‬ Tires                                         ‫اﻹﻃﺎرات‬

5
N/A No Yes

Comments ‫ﻣﻼﺣﻈﺎت‬ Horn                                      ‫اﻟﺘ ﺒ ﻪ‬ ‫آﻟﺔ‬

6
N/A No Yes

Comments ‫ﻣﻼﺣﻈﺎت‬ Lift/Tilt Cylinder   ‫اﻹﻣﺎﻟﺔ‬ / ‫اﻟﺮﻓﻊ‬ ‫إﺳﻄﻮاﻧﺔ‬

7
N/A No Yes

Comments ‫ﻣﻼﺣﻈﺎت‬ Fire Extinguisher              ‫اﻟﺤ ﻖ‬ ‫ﻃﻔﺎ ﺔ‬

8
N/A No Yes

Comments ‫ﻣﻼﺣﻈﺎت‬ Forks                                     ‫اﻟﺸﻮﻛﺘﺎن‬

9
N/A No Yes

‫ﻣﻌﺪﻧ ﺔ‬ ‫ ﻄﺎﻧﺔ‬ / ‫اﻹﺳﻨﺎد‬  ‫ﻗﻮ‬

Comments ‫ﻣﻼﺣﻈﺎت‬
Load Backrest 
10
N/A No Yes

Comments ‫ﻣﻼﺣﻈﺎت‬ Mast                                         ‫اﻟﺼﺎري‬

11
N/A No Yes

Comments ‫ﻣﻼﺣﻈﺎت‬ Oil Leakage                     ‫اﻟ ﺖ‬ ‫ﺗﻬ ﺐ‬

12
N/A No Yes
 ‫ﻟﻠﻤﺸﻐﻞ‬  ‫اﻟﻴﻮ‬ ‫اﻟﻔﺤﺺ‬
Comments ‫ﻣﻼﺣﻈﺎت‬ Comments ‫ﻣﻼﺣﻈﺎت‬ Load Chart              ‫ﻟﻠﺤﻤﻞ‬  ‫اﻟﺒ ﺎ‬ ‫اﻟﺮﺳﻢ‬
Daily Inspection (Operator)  
14 13
N/A No Yes N/A No Yes

Comments : : ‫ﻣﻼﺣﻈﺎت‬

‫اﻟﺘﻮﻗﻴﻊ‬  ‫اﻟﻤﺸﻐﻞ‬ ‫إﺳﻢ‬
Signature Operator Name
‫ﺗﻮﻗ ﻌﻪ‬ ‫اﻟﻤﻌﺪات‬ ‫ﻗﺴﻢ‬ ‫ﻣﺴﺆول‬
‫اﻹﻋﺘﻤﺎد‬

Signature EQ Dep Response
‫ﺗﻮﻗ ﻌﻪ‬ ‫اﻟﺴﻼﻣﺔ‬ ‫ﻣ ف‬
Signature Safety Supervisor
‫ﺗﻮﻗ ﻌﻪ‬ ‫ﻣﺔ‬ ‫اﻟﺴﻼ‬ ‫ﻣﻬﻨﺪس‬
Signature Safety Engineer
 In Case The Equipment Excluded Please Reason For Exclusion  /                      /              : ‫اﻹﺳ ﻌﺎد‬ ‫ﺗﺎر ــﺦ‬ ‫اﻹﺳ ﻌﺎد‬ ‫ﺳ ﺐ‬ ‫ذﻛﺮ‬ ‫اﻟﺮﺟﺎء‬ ‫اﻟﻤﻌﺪة‬ ‫إﺳ ﻌﺎد‬  ‫ﺣﺎل‬ 

‫اﻟﺘﻨﻔ ﺬي‬ ‫اﻟﻤﺪﻳﺮ‬               ‫اﻟﺴﻼﻣﺔ‬ ‫ﻣﺪﻳﺮ‬             ‫اﻟﺴﻼﻣﺔ‬ ‫ﻣﻬﻨﺪس‬ 

‫اﻹﻋﺘﻤﺎد‬

Constructio Manager  Safety Manager Safety Engineer 

‫ﺗﻮﻗ ﻌﻪ‬ ‫ﺗﻮﻗ ﻌﻪ‬ ‫ﺗﻮﻗ ﻌﻪ‬
Signature Signature Signature
Archive Received Date   :                     /                 /                   /                /               : ‫ﺑﺘﺎر ــﺦ‬ ‫اﻷرﺷ ﻒ‬ ‫إﺳﺘﻼم‬
At The Time Of Inspection, This Equipment Was Safe For Work On The Project  ‫اﻟﻔﺤﺺ‬ ‫وﻗﺖ‬ ‫أﺛﻨﺎء‬ ‫وع‬ ‫ ﺎﻟﻤ‬ ‫ﻟﻠﻌﻤﻞ‬ ‫آﻣﻨﺔ‬ ‫اﻟﻤﻌﺪة‬ ‫ﻫﺬە‬