PT.

MANOOR BULATN LESTARI

FORMULIR KOMISSIONING LIGHT VEHICLE

Tanggal Komissioning/Date :_____________ KM/HM :______________

Tipe Unit/Type Unit :_____________ Perusahaan/Campany :______________
No. Kendaraan/No.Plat :_____________ Akses Jalan /Road Access :______________
No.Mesin/No.Engine :_____________

LAYAK TIDAK
No ITEM YANG DIPERIKSA LAYAK KETERANGAN
LUAR KABIN
1 Body Unit dan Reflective tape
2 Warna Bodi Unit (Putih,Silver)
3 Pintu Kabin (Cabin door)
4 No.unit Jelas jarak 100 mtr
5 Buggy Whip (Min 4 meter)
6 Kaca Spion kiri & kanan
7 Wipers &Washer
8 Roda (Tyer dan Velg)
9 Ganjal ban (Wheel Chock)
10 Kerucut (Safety Cone) 2 unit
DALAM KABIN
11 Tempat Duduk (Seat)
12 Sabuk Pengaman (Seat Belt)
13 Radio Komunikasi Rig
14 Kemudi (Steering)
15 Panel Indikator & Gauge
16 Kotak P3K (First Aid Box)
17 APAR
18 Kunci Baut Roda (Tools)
19 Dongkrak (Jack)
UNIT DIOPERASIKAN
20 Klakson (Horn)
21 Alarm Mundur
22 Tansmisi & Perseneling
23 Rem Tangan (Hand Brake)
24 Rem Kaki (Service Brake)
25 4 WD (Double Gardan)
26 Lampu Rem, Sein &Hazard
27 Lampu Rotary Blitz (>30 Watt)
28 Lampu Depan (Head Light)
29 Mesin (Engine)
HASIL KOMISSIONING / Result Commissioning

Layak Dioperasikan/Good to operation Tidak Layak Dioperasikan/ No Good to operation

Prepare By, Chack By, Know By, Approve By,

Kontraktor/Rental Mekanik HSE KTT