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Form Inspeksi Tabung Oksigen

No. Bagian Oke Not Oke Keterangan


1. Safety Disc
2. Valve
3. Cylinder Pressure Gauge
4. Working Pressure Gauge
5. Regulator
6. Regulator Adjusting Screw
7. Oxygen Cylinder
8. Oxygen Hose
9. Flashback Arrestor

Inspected by : Approved by :
Name : Name :
Position : Position :
Date : Date :
Signature : Signature :

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