H 

S E   D E P A R T M E N T 
I N S P E C T I O N    F O R M

INSPECTION :

LOCATION / PROJECT :

PERIOD :

DATE / TIME REPORTING :

MONTHLY

IMPLEMENTATION REMARKS /
NO. DESCRIPTION
Yes No N/A RECOMMENDATION

I. PRODUCE WASTE ACTIVITY

Produce Biodegradable Domestic Waste Solid (food waste)

1.1
Menghasilkan limbah domestik Biodegradable (sisa makanan)

Produce Burnable Solid Waste (Paper, Cardboard, Carton,etc)

1.2
Menghasilkan Limbah yang dapat dibakar (kertas, Kardus, Karton, dll)

Produce Non Burnable Solid Waste (rubber,tin, Plastic, etc.)

1.3
menghasilkan limbah yang tidak boleh dibakar ( Karet, Timah, Plastic, etc)

Produce Hazardous Solids Waste (Batteries, Grease, Lights, etc)

1.4
Menghasilkan limbah padat B3 (Batterai, Gemuk, Lampu, Dll)

Produce Hazadous Liquid Waste (Lubricating Oil, chemical, paints,etc)

1.5
Menghasilkan limbah cairan B3 ( minyak pelumas, chemical, cat)

Produce Contaminated Waste ( gloves, cotton Waste, etc.)

16
1.6
menghasilkan limbah terkontaminasi(sarung tangan,majun)

Produce Medical Waste

1.7
Menghasilkan limbah medic

Produce Grey water (kitchens/wash rooms)

1.8
Menghasilkan air kotor kegiatan mandi, cuci(mandi,Cuci)

Produce Black water (toilets)

1.9
Menghasilkan air kotor septik tank (tinja)

Emergency spill kit available (e.g. absorbent, oil boom, etc)

1.10
keadaan darurat tumpahan minyak Kit tersedia

Waste Transfer Note Document

1.11
Document catatan pengiriman sampah

Waste tranfser log book

1.12
Tanda bukti pencatatan sampah

II. WASTE SEGREGATION (PEMISAHAN LIMBAH)

Rubbish Bins
2.1
Tempat Sampah

Colour code rubbish bins

2.2
kode warna tempat sampah

Dumpster
2.3
tempat pembuangan sementara

Isolasi Hazardous Waste Area

2.4
isolasi limbah isolasi
 III. MEASUREMENT / PENGUKURAN

Noise Measurement
3.1
Pengukuran kebisingan
Lux Measurement
3.2
Pengukuran cahaya
Anemometer Measurement
3.3
Pengukuran kecepatan angin
Humidity Measurement
3.4
Pengukuran kelembaban
Temperature Measurement
3.5
Pengukuran suhu
Air Emission Measurement
3.6
Pengukuran udara emisi
Air Ambien Measurement
3.7
Pengukuran udara Ambient
Sample of Fresh Water
3.8
Sample air bersih
Sample of Drinking water
3.9
Sample air minum
Dust Measurement
3.10
Pengukuran Debu
IV. HAZARD COMMUNICATION

HSE Policy
4.1
Kebijakan HSE

Environmental Programe
4.2
Program lingkungan

Symbol material hazardous and waste hazardous waste

4.3
Simbol bahan berbahaya dan limbah berbahaya

Label Smoking Area

4.4
Label area merokok

MSDS available and displayed at the respective area

4.5
MSDS tersedia dan ditampilkan diarea masing-masing)

Waste Disposal Flowchart

4.6
Alur Pembuangan sampah

Oil spill contingency plan flow chat

4.7
Diagram aliran keadaan darurat tumpahan minyak

V. OTHERS

Recommendation :

* Yes : Ada dan dilaksanakan

* No : Ada tapi tidak dilaksanakan
* N/A (Not Available) : Tidak Ada sama Sekali

                    Approved by, Inspection by,

                    Muhammad Ali Wafa Abd. Aziz

                    Env Engineer Env Officer
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