CEK LIST PERALATAN

Inspection area : PT. Amarta Indonesia Makmur 1st Floor

Date /Time of Inspection :

Workplace / area Inspected :

Inspected by :

Safety Rep. In charge :

CORRECTIVE ACTION DUE PERSON IN

NO. ITEM OF INSPECTION CONDITION
TAKEN DATE CHARGE

BAIK TIDAK NA

1 Gauges/indicators Baik
2 Lights/signals Baik
3 Horn/backup alarm Baik
4 Controls operate smoothly/labeled Baik
5 Brakes & park brake Baik
6 Seat belt Baik
7 Fire extingusher-charged/inspected Baik
8 Manual-operators,capacity/charts Baik
9 Glass/Mirrors Baik
10 License plate w/ copy of registration Baik
11 Engine oil level / leaks Baik
12 Coolant level/leaks, radiator clean Baik
13 Hoses/wiring Baik
14 Air cleaner(s) / pre-cleaner / intake Baik
15 Electrical - battery/alternator/starter Baik
16 Transmission - gears/oil/level/leaks Baik
17 Hydraulic oil level, leaks,cylinders Baik
18 Tire press/condition,lug nuts Baik
19 Pivot / wear poitns-greased Baik
20 Condition of power cords and cable Baik
21 Condition of plugs and wall outlets Baik
22 Material Safety Data Sheets available Baik
23
24

Diperiksa oleh,

HSE Coordinator
 CEK LIST JSA
JOB SAFETY ANALYSIS WORKSHEET

JOB :

Analysed by : Date :

Reviewed by : Date :

Approved by : Date :

Sequence of Task / Urutan Pekerjaan Potential Hazard / Potensi Bahaya Preventive Measures / Tindakan
Pencegahan
 CEK LIST PERALATAN

Inspection area : PT.AMARTA INDONESIA MAKMUR

Date /Time of Inspection :

Workplace / area Inspected : JAKARTA KRAMAT RAYA 5E

Inspected by :

Safety Rep. In charge :

PERSON IN
NO. ITEM OF INSPECTION CONDITION CORRECTIVE ACTION TAKEN DUE DATE
CHARGE

BAIK TIDAK NA

Workplace / area Inspected : LANTAI 1

1 Fire Extinguisher (Type :Powder) Baik Baru 5/29/2015
2 Fire Extinguisher (Type :FOAM) Baik Isi Ulang/ Tgl. 12-2-2013 2/12/2014

Workplace / area Inspected : LANTAI 2

1 Fire Extinguisher (Type :FOAM) Baik Isi Ulang/Tgl. 12-2-2013 2/12/2014
2 Fire Extinguisher (Type :CO2) Baik Baru 5/29/2017

Workplace / area Inspected : LANTAI 3

1 Fire Extinguisher (Type :Powder) Baik Baru 5/29/2015
2 Fire Extinguisher (Type :CO2) Baik Baru 5/29/2017

Diperiksa oleh,

H. ANNA NURYANTI
HSE Coordinator
 CEK LIST PERALATAN (FIRST AID BOX)

Inspection area : PT.AMARTA INDONESIA MAKMUR

Date /Time of Inspection :

Workplace / area Inspected : JAKARTA KRAMAT RAYA 5E

Inspected by :

Safety Rep. In charge : HJ ANNA NURYANTI

PERSON IN
NO. ITEM OF INSPECTION CONDITION QTY CORRECTIVE ACTION TAKEN DUE DATE
CHARGE

HJ ANNA
(FIRST AID BOX) BAIK TIDAK NA BARU 30/05/2013
NURYANTI

Workplace / area Inspected : LANTAI 1 (PANTRY)

1 Antiseptik Iodine Betadine isi 60 ml 1 Botol 3/1/2016 H. A. N.
2 Antiseptik Alkohol 70% isi 285 ml 1 Botol 9/27/2018 H. A. N.
3 Plester Putih 3M Surgical Tape isi 1 roll 1 Buah n/a H. A. N.
4 Plester Hansaplast isi 10 Strip 2 Pak 2/1/2016 H. A. N.
5 Kasa Hidrofil Steril 16cm/16cm 2 Pak n/a H. A. N.
6 Kasa Pembalut isi 10 Buah 1 Pak n/a H. A. N.
7 Kapas Pembalut isi 50 gr 1 Pak n/a H. A. N.
8 Cotton Buds isi 100 Pcs 1 Pak n/a H. A. N.
9 Minyak Kayu Putih Cap Lang 125 ml 1 Botol 3/1/2018 H. A. N.
10 Minyak Gosok Cap Tawon 90 ml 1 Botol n/a H. A. N.
11 Gunting 1 Unit n/a H. A. N.
12 H. A. N.
13 H. A. N.
14 H. A. N.
15 H. A. N.
16 H. A. N.
17 H. A. N.
18 H. A. N.
19 H. A. N.
20 H. A. N.
Diperiksa oleh,

H MUH FAISAL AMRON-DIREKTUR

PT. AMARTA INDONESIA MAKMUR
 CEK LIST PERALATAN (APD)

Inspection area : PT.AMARTA INDONESIA MAKMUR

Date /Time of Inspection :

Workplace / area Inspected : JAKARTA KRAMAT RAYA 5E

Inspected by :

Safety Rep. In charge : EFIAN SUTISNA

PERSON IN
NO. ITEM OF INSPECTION CONDITION QTY CORRECTIVE ACTION TAKEN DUE DATE
CHARGE

(Alat Pelindung Diri) BAIK TIDAK NA Efian Sutisna

Workplace / area Inspected : Rak APD (LANTAI 1)

1 Safety Helmet (Putih) 6 Buah E.F.
2 Ear Muff (Pelindung Telinga) 2 Buah E.F.
3 Safety Shoes/ Boots 2 Pasang E.F.
4 Safety Glasses 5 E.F.
5 Alat Pelindung Pernafasan 1 E.F.
6 Filter Alat Pelindung Pernafasan isi 6 buah 1 Box E.F.
7 Safety Harness (Body/Badan) 1 Set E.F.
8 Safety Belt (Waist/Pinggang) 1 Set E.F.
9 Safety Gloves (Sarung Tangan) 12 Pasang E.F.
10 E.F.
Diperiksa oleh,