INSPEKSI ALAT DAN PERALATAN

Form-I-002
CRANE INSPECTION FORM

Type of Crane : CARRY-IN CERTIFICATE

Equipment No. : Permit No. :

Capacity : Date :

Manufacturer :
Approved by :
Company User :

Certificate Number :
Reviewed by :
Month of Inspection :
This form must be completed by the crane operator and company user before entering the crane to be operated in the
site project area, and at any time of setting location. All crane condition must meet to the safety regulation and ADHI
SHE Management Plan
Result column: (  ) Yes/Good, Acceptable, ( X ) Not/Bad, Not to use, ( NA ) Not applicable

No Check Item Result Remarks

1 Operator has a valid License

2 Equipment has valid certificate
3 Hydraulic system in good condition
4 Crawler/Tire condition
5 Boom / Fly Jeep
6 Block Hook
7 Hook Completed with Safety latch
8 All electrical system are in good
9 Brake system
10 Operations Handle
11 Back Mirror
12 Lighting Device
13 Alarm System
14 SWL Chart Provided/Displayed
15 Wire sling is in good condition ?
16 Rigger man provided / qualified ?
17 Fork horn in good condition ?
18 Lubrication system
19 Oil leaking
20 Fuel Reservoir
21 Each Side of windows glasses
22 Leveling indicator devices
23 Auxiliary Drum
24 Fire Extinguisher
INSPEKSI ALAT DAN PERALATAN

INSPECTOR REPORT
Corrective Action Required

Inspection Status:  OK

 Not OK

 Order for Repair

Contractor
Inspected by Date : Name : Signature :
Position :

Approved by Date : Name : Signature :

Position :

PT Pertamina
Inspector Date : Name : Signature :
Position :