Synthetics Rubber Indonesia – U3 Project

SOIL HANDLING EQUIPMENT

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

□ Bulldozer □ Backhoe □ Road Roller □ Power Shovel □ Drag-line

□ Clamshell □ Grader □ Scraper □ Wheel Loader Excavator
Type of Equipment : OPERATOR LICENSE

Equip No./ Tag No. : Operator Name :

Manufacturer : SIO Type :

Company User :
SIO Number :
Certificate Number :

Month of Inspection : Validity :

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

1 Operator has a valid License

2 Equipment has valid certificate
3 Certificate Emission Test
4 Hydraulic system in good condition
5 Traveling system in good condition
6 All electrical system are in good
7 Brake system
8 Operations Handle
9 Back Mirror
10 Lighting Device
11 Alarm System
12 Crawler / Tire condition
13 Safety device
14 Rigger man provided / qualified
15 Fork horn in good condition
16 Lubrication system
17 Safe Guards for moving parts
18 Oil leaking
19 Fuel Reservoir
20 Fire Extinguisher
 Synthetics Rubber Indonesia – U3 Project
SOIL HANDLING EQUIPMENT
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 :