Synthetics Rubber Indonesia – U3 Project

LIGHT VEHICLE INSPECTION

EMPLOYER / ITB Doc No. :
Client Work No.: U3 CLASSIFICATION: D3
Project Doc. No.: 14122-ED-00-QA-PRC-0019

CLASS AREA DIS TYP SUB-TYP SEQ SHEET REV. Page 1 of 2

Contractor Work No.: 14122
ED 00 QA PRC 0019 0 Date : 2015-12-04

INSPECTION FORM

□ Light Vehicle □ Bus □ Medium Duty Truck □ Heavy Duty Truck

Type of Equipment : DRIVER LICENSE

Equipment No. : Driver Name :

Capacity : SIM Type :

Manufacturer :
SIM Number :
Company User :

Certificate Number :
Validity :
Month of Inspection :
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 CONTRACTOR SHE Management Plan
Result column: (  ) Yes/Good, Acceptable, ( X ) Not/Bad, Not to use, ( NA ) Not applicable
No Check Item Result Remarks

DRIVER PERMIT
1
Valid RI Driving License
SEAT & SEAT BELT WORN
2
Seat belt lock mechanism working
DOORS – All door close tight
3
Doors handles on inside & out site in
working order.
4 TIRE CONDITION ( Including spare )
LIGHT/ BRAKE WORKING
5
All head lights, signal , brake and parking
brake working
INTERIOR
6
All gauges, indicator light & panel light
working
GENERAL VEHICLE & CONTENTS
7
- Jack & wheel wrench in place
- First aid kit
WINDSHIELD AND MIRRORS
8
- Clean, no major crack.
- Windshield wiper working
9 POWER STEERING
 Synthetics Rubber Indonesia – U3 Project
LIGHT VEHICLE INSPECTION
EMPLOYER / ITB Doc No. :
Client Work No.: U3 CLASSIFICATION: D3
Project Doc. No.: 14122-ED-00-QA-PRC-0019

CLASS AREA DIS TYP SUB-TYP SEQ SHEET REV. Page 2 of 2

Contractor Work No.: 14122
ED 00 QA PRC 0019 0 Date : 2015-12-04

10 ENGINE
11 CERTIFICATE EMISSION TEST
12 BATTERY / WIRING
13 RADIATOR / PUMP / FAN BELT
14 HORN / REVERSE ALRM
15 FIRE EXTINGUISHER ( 3 Kg )

INSPECTOR REPORT
Corrective Action Required

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

Subcontractor
Inspected by Date : Name : Signature :
Position :
Approved by Date : Name : Signature :
Position :
Contractor
Inspector Date : Name : Signature :
Position :
Approved by Date : Name : Signature :
Position :