FORM I
FORMULIR INSPEKSI PASAR 
( UNTUK PETUGAS )

I. DATA UMUM :

1. NAMA PASAR :
2. ALAMAT PASAR :
3. NAMA PENGELOLA PASAR :
( PENANNGGUNGJAWAB )
4. JUMLAH KIOS / LOS :
5. JUMLAH PEDAGANG :
6. JUMLAH ASOSIASI/
  KELOMPOK PEDAGANG :

II. DATA FISIK :

NO VARIABEL UPAYA BOBOT KOMPONEN YANG DINILAI NILAI SCORE

1 2 3 4 5 6
LOKASI
A 5
(N!" M"#$%"! 5&&)
1. S'$" R'*"" U%% T"+"
2&
R",
2. T-"# +'!'+"# "-" -"'"0
2&
"" '*""
3. T-"# +'!'+"# "-" -"'"0
2&
"" #'*'!"#""
4. T-"# +'!'+"# "-" -"'"0
2&
 '#"$
5. M'%" "+"$ !""0
2&
", '!"$
B BANGUNAN
PASAR  2&
Nili !"#i!l 2$$$
1 U!%! &5 B"," -" "*", ", 1&&
 

$'$" -'," '"+" ",

 '!"#
2 P&'(' )%'* 1. P'%"," "'" $'$" -',"
4 25
+*'*  '+#"" (7,)
2. 87, -'," -'++"$
5
!',#"
3. L'" !77, "+" !7$
15
%%"! 15 %'+'
4. J""# +'%"+ '"%,"
-" '%7+7," ,,"$
-'," "," "$" &
%%"! 1& %'+' "+"
-"+"$ +'%7# 
5. P'$+$-" -" "0" '"0""
 '"* +'$"0 -'," 7" 15
%"#"" -" "0" ","
3. R%'* "'(,) 1. 9'+!"$ %%"! 2&  -"
&5
-&'*&l,l !"$ !"+"
2. P'*"0""" %%"! 1&& !;
3. T'$'-" +7!'+ -" +'%"+ **
+","
4. T&!-( -&'%l'
/0' -'*' +' 15
!"''
4.1 T&!-( -&'%l' 1. M'" +'%"+ '"!" (!"
4
/0' -'*' /#0 1&)
". T"0" #""+ 4
 . R"+" 2
*. K'%," 2
-. T,, 6& *% 2
2. K"#"$ -",, -,"+, 4
3. A!"$ '%7+7, (+"!'") +-"# 
+'"+ -" #" +-"#
15
 '"* #'-" " -" %-"0
-'$0#"
4. T'%"+ '%"" "0" 15
 "," -'," "+" -,
 

(cold chain) '$0
(4<1& &=)
5. T'$'-" +'%"+ '**"
>
 "0" "," -" '"!"+"
6. T'%"+ ** +"," -!',#"
(!" 14):
". S" 6
 . A %',"! >
?. S"!" '%"," !%"0
(!" 1&) :
". T'++ 5
 . K'%," 5
>. T'%"+ $"%"0 (!" 1&) :
". T'$"0 ($"%"0 "$"0
4
@ #',)
 . K'-" " 3
*. T'+ 3
. B'"$ "+", '!"
 '"#+ ('#+7) @ +'%"+
 '-#""
4.2 T&!-( -&'%l' 3 1. M'" +'%"+ '"!"
/0' -'*' "&)i'* -',": '%#"" "+"
%-"0
-'$0#" -'," +,,
%%"! 6& *% ( !" 2& )
". P'%#"" "+" 1&
 . M-"0 -'$0#" 5
*. T,, %%"! 6& *% 5
2. M'" +'"+ -" "0" +"0" 2&
3. T'%"+ $"%"0 (!" 2&) :
". T'$"0 "$"0 -" #', &
 . K'-" " 5
*. B'++ 5
4. T'%"+ ** +"," -!',#"
(!" 2&) :
. D'," $" &
 . A %',"! 14
5. B'"$ '#+7 '!" '"#+
2&
-"
4.3 T&!-( -&'i' 3 1. T'%"+ '"" %"#""
( !" 2& )
!"''
 

!('*#i- #i
  ". T'++ 4
  . B"0" T"0" K""+ 3
  *. P'%#"" R"+" 3
  -. M-"0 -'$0#" 3
  '. T,, M%"! 6& *% 3
2. T'%"+ ** +"," -!',#"
(!" 2&):
  ". D'," $" 6
  . A %',"! 14
3. T'%"+ ** '"!"+" (!"
2&) :
  ". K"+ 6
  . A%" 4
  *. T-"# '#""+ 4
  -. M-"0 -'$0#" 6
4. P$" ", -,"#" +# 1&
%'%7+7, "0" %'+"0 -"
 "0" %"+", ''-" -"
+-"# '#""+
5. S"!" '%"," !%"0  
  (!" 1& ):
". T'++ 5
  . K'%," 5
6. T'%"+ $"%"0 (!" 1&) :
  ". T'$"0 "$"0 -" #', &
  . K'-" " 2
  *. B'++ 2
?. B'"$ '#+7 '!" '"#+ 1&
-" +'%"+ '-#""
4.4 A)& P)"i) 1 1. A-" '%$"0 ", '!"$ 15
-'," "+"$ !""0 "$" 
2. P"# %7! %7+7 $''-" 1&
"-7,/-'!%" '*"#
+'$"0
3. T'$'-" "'" "# #0$$ 1&
#'-""" ',",#+ 0'"
0-
4. T'$'-" "'" #0$$ 7,#" &
%"+ "",
5. T-"# "-" ,'"," " 1&
 

6. T'$'-" +'%"+ $"%"0 $'+" 15

"-$ 1& %'+' 15
 
?. A-" "! -" +"-" %"$# 1&
-" #'!" #'-""" ",
 '!"$

>. A-" +""%" ',0"" 1&

. A-"" "'" '$"" " 1&

4.4 K,'#()%"#i : 4
4.5.1 A(- &5 1. A+" (!" 4&)
". K"+ 2&
 . T-"# 7*7 1&
*. T-"# %'"- +'%"+ 1&
 '-#" '*+7 
2. K'%," "+" *# -"
+-"# %'%,##" 4&
,'"," " 
3. A+" -'," #'+,," !'0
1& %'+' -!',#"
 '",#"! '+ 2&
4.5.2 Di'+i'* &5 1. K'"-"" --, (!" 4&)
". B'$0 15
 . T-"# !'%" 15
*. B'"" +'", 1&
2. P'%#"" --, ",
$'!"! +'#'" '*#" "
+'"+ -" (!" 4&) :
  ". B"0" ", #"+ 2&
  . K'-" " 2&
3. P'+'%" !"+" -'," &
--, 0"$ !',#,
(*7$)
4.5.3 L'(i &5 1. K'"-"" !"+" (!" ?&) :
  ". K'-" " 15
  . R"+" 15
  *. T-"# !* 15
  -. T-"# '+"# 1&
  '. M-"0 -'$0#" 15
 

2. L"+"K"%" %"- T'%"+ 3&

** -" $''$"
%'%" #'%," #'
$"!" '%","

4.5.4 T'** &5 1. T,, !'" #'%," 4&

$'$" -'," #'+'+" ",
 '!"#

2. T'-""+ ',"," +"," 2&

3. K"+ -" +-"# !* 2&
4. P'*"0""" %%"! 1&& !; 2&
4.5.5 V&'(il#i 1 M%"! 2& -" !"$ !"+" 1&&
4.5.6 P&'0' &5 I+'$+"$ '*"0"" *# 1&&
+# %'!"##" +,"$
 ',7!"0" -" '%'$0"
 "0" %"#"" %%"! 1&& L;
4.5. Pi'(% &5 K0$$ !7$/#7$ '"! -",,  &
#" -" $''$"
%',,"#" + ", -""+
-#" -" %'++ $'- "+"
 !"$+* +# %',0"!",
 "+", "+" $'",," '!"
 '"#+.
SANITASI 3&
C
 Nili Mi'i!l 3$$$
Ai) B&)#i0 4 1. A '$0 $'!"! +'$'-" 4&
1 -"!"% %!"0 %%"!
( 4& L+' ''-",",)
2. K"!+"$ " '$0 %'%'0 3&
$""+ #'$'0"+"
3. J""# $%' " '$0 2&
-'," $'+*#+"# %%"!
3& *%
4. P'," " '$0 -!"##" 1&
6 !" $'#"!
2 K!) !'+i +' 4 1. T7!'+ : !"#<!"# -"
 

T,il&(  ''%" +'$"0 -',"

 %!"0 *# (!" 1&)
  ". T'$"0 5
  . J%!"0 *# 5
2. T'$'-" "# -" " '$0 1&
-'," %!"0 *# -"
 '"$ '+# 
3. T7!'+ -'," !'0' ",$" 1&
4. T'$'-" +'%"+ ** +"," &
-" $"
5. T'$'-" +'%"+ $"%"0 ", 1&
+'++
6. T'$'-" $'+# +"# -'," 1&
!", ''$"" ",
%'%'0 #'$'0"+"
?. L'+"# +7!'+ %%"! 1& %'+' 1&
-" '"! %"#"" -"
 "0" %"#""
>. 9'+!"$ %%"! 2& -" 1&
!"$ !"+"
. P'*"0""" %%"! 1&& !; 1&
1&. L"+" #'-" " +-"# !* 1&
%-"0 -'$0#" -',"
#'%," ", *#
P&'*,l0' S!-0 4 1. S'+" #7$/!77,/!7$ +'$'-" &
3 +'%"+ $"%"0 "$"0 -"
#',
2. T'%"+ $"%"0 +'"+ -"
(!" 2&) :
". B"0" #'-" " 5
 . T-"# %-"0 '#""+ 5
*. K"+ 4
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