Synthetics Rubber Indonesia – U3 Project

CRANE 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

Type of Crane : OPERATOR LICENSE

Equip No. / Tag No. : Operator Name :

Capacity : SIO Type :

Manufacturer :
SIO No :
Company User :

Certificate Number :
Validity
Month of Inspection :
This form must be completed by the crane operator and company user before entering the crane to be
operated in the site project area, and at any time of setting location. All crane 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

1 Operator has a valid License

2 Equipment has valid certificate
3 Certificate Emission Test
4 Hydraulic system in good condition
5 Crawler/Tire condition
6 Boom / Fly Jeep
7 Block Hook
8 Hook Completed with Safety latch
9 All electrical system are in good
10 Brake system
11 Operations Handle
12 Back Mirror
13 Lighting Device
14 Alarm System
15 SWL Chart Provided/Displayed
16 Wire sling is in good condition ?
17 Rigger man provided / qualified ?
18 Fork horn in good condition ?
19 Lubrication system
20 Oil leaking
21 Fuel Reservoir
22 Each Side of windows glasses
23 Load indicators
24 Leveling Indicator devices
25 Auxiliary Drum
26 Fire Extinguisher
 Synthetics Rubber Indonesia – U3 Project
CRANE 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

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 :
Reviewer Date : Name : Signature :
Position :
SHE Manager Date : Name : Signature :
Position :