SHE-F03 rev.

2
FIRE EXTINGUIESHER INSPECTION CHECKLIST
KONDISI APAR
UKURAN TANGGAL KADARLUARSA /
NO CODE LOKASI AREA NO APAR
(KG) EXPIRED DATE Handle / Tekanan / Pin Kadarluarsa Keterangan
Selang Serbuk
Gagang Pressure Pengaman Yes No
1 220 P1 Parkir P01 220 4 22 September 2007
2 221 P2 Parkir P02 221 4 22 September 2007
3 222 P3 Parkir P03 222 4 22 September 2007
4 219 P4 Parkir P04 219 4 22 September 2007
5 217 B1 Parkir (B1) B01 217 4 22 September 2007
6 184 B1 Parkir (B1 Lift) B01 184 4 22 September 2007
7 12 B1 Hydrant Gudang B01 012 4 22 September 2007
8 13 B1 Posko Truck Dock B01 013 2 22 September 2007
9 218 B1 Posko Pintu Masuk B01 218 4 22 September 2007
10 189 B1 Parkir Motor B01 189 2 08 Mei 2007
11 11 B1 Gudang B01 011 3.5 17 Oktober 2007
12 158 B2 Parkir (B2 D) B02 158 4 22 September 2007
13 183 B2 Parkir (Lift) B02 183 4 22 September 2007
14 102 B3 Parkir (B3 D) B03 102 4 22 September 2007
15 108 B3 Parkir (B3 Lift) B03 108 4 22 September 2007
16 27 G Hydrant G00 027 4 22 September 2007
17 28 G Hydrant G00 028 4 22 September 2007
18 100 G Smoking Room G00 100 2 29 Maret 2007
19 31 1 GNTU L01 031 2 22 September 2007
20 34 1 Hydrant L01 034 2 29 Maret 2007
21 44 2 Hydrant L02 044 2 22 September 2007
22 43 2 Hydrant L02 043 2 22 September 2007
23 50 3 Hydrant L03 050 2 08 Mei 2007
24 49 3 Hydrant L03 049 2 31 Maret 2007
25 55 4 Hydrant L04 055 2 29 Maret 2007
26 56 4 Hydrant L04 056 2 29 Maret 2007
27 60 5 Hydrant L05 060 2 29 Maret 2007
28 61 5 Hydrant L05 061 2 29 Maret 2007
29 65 6 Hydrant L06 065 2 22 September 2007
30 66 6 Hydrant L06 066 2 22 September 2007
31 71 7 Hydrant L07 071 2 22 September 2007
32 72 7 Hydrant L07 072 2 22 September 2007
33 79 8 Hydrant L08 079 2 22 September 2007
34 80 8 Hydrant L08 080 2 22 September 2007
35 84 9 Hydrant L09 084 2 22 September 2007
36 85 9 Hydrant L09 085 2 22 September 2007
37 89 10 Hydrant L10 089 2 22 September 2007
38 90 10 Hydrant L10 090 2 22 September 2007
39 96 11 Hydrant L11 096 2 22 September 2007
40 97 11 Hydrant L11 097 2 22 September 2007
 SHE-F03 rev.2
FIRE EXTINGUIESHER INSPECTION CHECKLIST
KONDISI APAR
UKURAN TANGGAL KADARLUARSA /
NO CODE LOKASI AREA NO APAR
(KG) EXPIRED DATE Handle / Tekanan / Pin Kadarluarsa Keterangan
Selang Serbuk
Gagang Pressure Pengaman Yes No

41 103 12 Hydrant L12 103 2 22 September 2007

42 104 12 Hydrant L12 104 2 22 September 2007

43 109 14 Hydrant L14 109 2 22 September 2007

44 110 14 Hydrant L14 110 2 22 September 2007

45 119 16 Hydrant L16 119 2 22 September 2007
46 120 16 Hydrant L16 120 2 22 September 2007
47 126 17 Hydrant L17 126 2 22 September 2007
48 127 17 Hydrant L17 127 2 22 September 2007

49 131 18 Hydrant L18 131 2 31 Maret 2007

50 132 18 Hydrant L18 132 2 31 Maret 2007

51 136 19 Hydrant L19 136 2 31 Maret 2007

52 137 19 Hydrant L19 137 2 31 Maret 2007

53 143 20 Hydrant L20 143 2 22 September 2007

54 144 20 Hydrant L20 144 2 22 September 2007

55 153 22 Hydrant L22 153 2 22 September 2007

56 154 22 Hydrant L22 154 2 22 September 2007

57 159 23 Hydrant L23 159 2 22 September 2007

58 160 23 Hydrant L23 160 2 22 September 2007

59 164 24 Hydrant L24 164 2 22 September 2007

60 165 24 Hydrant L24 165 2 22 September 2007

61 172 25 Hydrant L25 172 2 29 Maret 2007

62 173 25 Hydrant L25 173 2 29 Maret 2007

63 177 26 Hydrant L26 177 2 22 September 2007

64 178 26 Hydrant L26 178 2 22 September 2007

LAPORAN HASIL PEMERIKSAAN NOTE

NAMA :
NIK :

TANGGAL : s/d

Inspektor Head of BS Head Of SHE

 SHE-F03 rev.2

FIRE EXTINGUIESHER INSPECTION CHECKLIST

KONDISI APAR
UKURAN TANGGAL KADARLUARSA /
NO CODE LOKASI AREA NO APAR
(KG) EXPIRED DATE Handle / Tekanan / Pin Kadarluarsa Keterangan
Selang Serbuk
Gagang Pressure Pengaman Yes No
1 214 B1 AHU&Panel B01 214 4 22 September 2007
2 8 B1 Control Room B01 008 4 22 September 2007
3 9 B1 PABX B01 009 2 22 September 2007
4 32 B1 Cadangan B01 032 2 22 September 2007
5 39 B1 Cadangan B01 039 2 22 September 2007
6 57 B1 Cadangan B01 057 2 22 September 2007
7 211 B1 Cadangan B01 211 2 22 September 2007
8 75 B1 Cadangan B01 075 2 08 Mei 2007
9 216 B1 Cadangan B01 216 2 29 Maret 2007
10 6 B2 DLU B02 006 21 22 September 2007
11 7 B2 Workshop B01 007 4 22 September 2007
12 4 B3 Chiller B03 004 25 22 September 2007
13 213 B3 Chiller B03 213 7 22 September 2007
14 3 B3 Electrical B03 003 25 22 September 2007
15 212 B3 Electrical B03 212 7 22 September 2007
16 199 B3 Fire Pump B03 199 4 22 September 2007
17 5 B3 STP B03 005 4 22 September 2007
18 1 B4 Genset B04 001 25 22 September 2007
19 2 B4 Genset B04 002 7 22 September 2007
20 36 1 Panel L01 036 2 22 September 2007
21 209 1 Server GNTU L01 209 6,5 08 Mei 2007
22 46 2 Panel L02 046 2 22 September 2007
23 52 3 Panel L03 052 2 22 September 2007
24 58 4 Panel L04 058 2 22 September 2007
25 63 5 Panel L05 063 2 22 September 2007
26 68 6 Panel L06 068 2 22 September 2007
27 74 7 Panel L07 074 2 22 September 2007
28 82 8 Panel L08 082 2 22 September 2007
29 87 9 Panel L09 087 2 22 September 2007
30 92 10 Panel L10 092 2 22 September 2007
31 99 11 Panel L11 099 2 22 September 2007
32 106 12 Panel L12 106 2 22 September 2007
33 112 14 Panel L14 112 2 22 September 2007
34 117 15 Panel L15 117 2 22 September 2007
35 122 16 Panel L16 122 2 22 September 2007
36 200 17 Lift Machine Room L17 200 4 22 September 2007
37 129 17 Panel L17 129 2 22 September 2007
38 134 18 Panel L18 134 2 22 September 2007
39 139 19 Panel L19 139 2 22 September 2007
 SHE-F03 rev.2

40 146 20 Panel L20 146 2 22 September 2007

 SHE-F03 rev.2

FIRE EXTINGUIESHER INSPECTION CHECKLIST

KONDISI APAR
UKURAN TANGGAL KADARLUARSA /
NO CODE LOKASI AREA NO APAR
(KG) EXPIRED DATE Handle / Tekanan / Pin Kadarluarsa Keterangan
Selang Serbuk
Gagang Pressure Pengaman Yes No
41 151 21 Panel L21 151 2 22 September 2007
42 156 22 Panel L22 156 2 22 September 2007
43 162 23 Panel L23 162 2 22 September 2007
44 167 24 Panel L24 167 2 22 September 2007
45 175 25 Panel L25 175 2 22 September 2007
46 180 26 Panel L26 180 2 22 September 2007
47 186 27 Panel L27 186 2 22 September 2007
48 192 28 Panel L28 192 2 22 September 2007
49 198 29 Heat Excharger L29 198 4 22 September 2007
50 201 29 Lift Machine Room L28 201 4 22 September 2007

LAPORAN HASIL PEMERIKSAAN NOTE

NAMA :
NIK :
TANGGAL : s/d

ttd
SHE Dept
No. Dokumen : xxx-FRM/HSE-00-36
Revisi : -- (Logo gedung)
Tanggal : 01 Juni 2012

CHECKKLIST FIRE PROTECTION SYSTEM

LANTAI :
HARI :
TANGGAL :

NO NAMA PERALATAN LOKASI JENIS PEMERIKSAAN HASIL PEMERIKSAAN KETERANGAN

I
1 Batery Charger - Periksa tegangan
2 Baterey - Periksa sambungan kabel
3 PCB 1/0 (In/Out) - Periksa kebersihannya
II
1 Slang ø 1,5", Nozzle - Periksa keadaan fisik bell
2 Kran ø 1,5" dan ø 2,5" - Periksa keadaan fisik lampu, BGU
3 Nozzle ø 1,5" - Periksa sambungan fire phone
4 Bell Alarm - Periksa tekanan pada meter APAR
5 Lampu Alarm - Periksa sambungan kabel PCB SCC
6 Fire Phone - Periksa kebersihan box hydrant
7 BGU (Break Glass Unit)
8 PCB SCC (Secundern Circuit Control)
9 Fire Extinguisher
III
1 Smoke Detector - Periksa keadaan fisiknya
2 Head Detector - Periksa kebersihannya
3 Sprinkler Head - Periksa tegangan
4 Speakker
IV
1 Panel MCFA - Periksa kebersihannya
2 Panel utama sounnd system - Periksa kondisi fisiknya
3 Baterey back up - Periksa tegangan
V
1 Instalansi pipa LZ, MZ & HZ - Periksa tekanan air
2 Tangki air bawah tanah (G.T.) - Periksa level air
3 Tangki bertekanan, LZ, HZ & HZ - Periksa kondisi fisik
4 Pompa jockey LZ, MZ & HZ - Periksa posisi MCCB & fungsi automatic
5 Pompa utama LZ, MZ & HZ - Periksa tegangan
6 Pompa diesel cadangan LZ, MZ & HZ
7 Pompa Baterey LZ, MZ & HZ
VI
1 Hydrant pillar - Periksa kran
2 Siamese connection - Periksa kebersihannya
3 Box hydrant, Slang ø 2,5", Nozzle - Periksa pen nepple

Catatan :
1). Point I, II, III, V, VI diperiksa satu minggu sekali
2). Point IV diperiksa satu bulan sekali
3). Pelaksanaan pemeriksaan tanpa mengganggu operational

Cc : Building Security Security Tekhnisi BE Supervisor Head of BE

Building Engineering
Safety, Health and Environment
Pengelola Properti: PT. Cushman & Wakefield Indonesia