INSPEKSI ALAT DAN PERALATAN

Form-I-011
GAS CUTTING/WELDING INSPECTION FORM

Type of Equipment : CARRY-IN CERTIFICATE

Equipment No. : Permit No. :

Company User : Approved by :

Month of Inspection : Reviewed by :

This form must be completed by the operator and company user before entering the equipment to be operated in the
site project area, and at any time of setting location. All equipment 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 Gas Cylinders
2 Regulator/Hoses/Torches
Regulator
Hoses/Connector
Torches
Flash-back Arrestor
3 Miscellaneous
Fire extinguisher
Fire prevention
Overturn Prevention (Basket)
Provision of Soap Liquid

INSPECTOR REPORT
Corrective Action Required

Inspection Status:  OK  Not OK  Order for Repair

Inspected by Date : Name : Signature :

Position :

Approved by Date : Name : Signature :

Position :