Internal

PROJECT MANAGEMENT OFFICE

SAFETY AND MAINTENANCE INSPECTION CHECK SHEET : (TRUCK/ DUMP TRUCK/ TANK TRUCK/ TRAILER)

INSPECTION ITEMS

1. GENERAL DATA

1. 1 Tanggal Inspeksi

1. 2 No. Register PMO

1. 3 Merek/ Unit

1. 4 Year Of Manufactor

1. 5 Type/ Model

1. 6 Rated Capacity

1. 7 No. Polisi

1. 8 No. KIUR

1. 9 SIM Pengemudi

1. 10 KIMPER Pengemudi

1. 11 Others…
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PROJECT MANAGEMENT OFFICE

2. GENERAL CONDITION CHECK LIST UNIT REMARKS
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31

2. 1 Kondisi ruangan dalam kabin/ kebersihan **

2. 2 Kondisi luar/ Badan kabin **

2. 3 Sistem air condtion **

2. 4 Fungsi panel/ Dash Board/layar monitor *

2. 5 Kaca depan *

2. 6 Kaca jendela kanan dan kiri **

2. 7 Sabuk Pengaman **

2. 8 Tempat duduk pengemudi dan penumpang *

2. 9 Kunci pintu kabin *

2. 10 Wiper *

2. 11 Tangga pijakan *

2. 12 Sistem pengemudi *

2. 13 Pedal gas, rem dan kopling *

2. 14 Others…

Note :
1. * = Daily
2. ** = Weekly
3. *** = Monthly
4. Original kept by HSE Department
5. Copy Kept by related contractor
6. Attached SIO, SILO, Certificate, Other related document
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PROJECT MANAGEMENT OFFICE

3. SAFETY REQUIREMENT CHECK LIST UNIT REMARKS
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31

3. 1 Fire extinguisher **

3. 2 First aid kit/ Box **

3. 3 Rotary lamp **

3. 4 Horn/ Klakson **

3. 5 lampu besar/ Utama **

3. 6 Lampu kecil/ Fog lamp **

3. 7 Lampu rem **

3. 8 Lampu mundur **

3. 9 Lampu sign kanan dan kiri **

3. 10 Alarm mundur **

3. 11 Dongkrak **

3. 12 Traffic cone/ Segitiga pengaman **

3. 13 Kunci roda **

3. 14 Ganjal ban/ Wheel chock **

3. 15 Others…
Note :
1. * = Daily
2. ** = Weekly
3. *** = Monthly
4. Original kept by HSE Department
5. Copy Kept by related contractor
6. Attached SIO, SILO, Certificate, Other related document
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PROJECT MANAGEMENT OFFICE

4. ENGINE CHECK LIST UNIT REMARKS
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31

4. 1 Kondisi ruangan mesin (Kunci berfungsi) **

4. 2 Kondisi mesin (Oli bocor, berkarat dan lain-lain) **

4. 3 Dudukan engine (Engine mounting) **

4. 4 Oli mesin/ level **

4. 5 Air radiator/ level bocor/penutup ada **

4. 6 Sambungan-sambungan selang **

4. 7 Pompa hydrolik **

4. 8 Baterry (Air,kunci,pengingat,dudukan,dll) **

4. 9 Lampu sign kanan dan kiri *

4. 10 Alarm mundur *

4. 11 Dongkrak *

4. 12 Traffic cone/ Segitiga pengaman *

4. 13 Others…
Note :
1. * = Daily
2. ** = Weekly
3. *** = Monthly
4. Original kept by HSE Department
5. Copy Kept by related contractor
6. Attached SIO, SILO, Certificate, Other related document
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PROJECT MANAGEMENT OFFICE

5. LIFTING EQUIPMENT CHECK LIST UNIT REMARKS
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31

5. 1 Kunci gandeng dalam keadaan bagus *

5. 2 Sambungan kabel-kabel ke trailer *

5. 3 sambungan selang hydrolic *

5. 4 Rem berfungsi dengan baik *

5. 5 Jack trailer berfungsi dengan baik *

5. 6 Ban cadangan tersedia ***

5. 7 Flatbed dalam kondisi baik *

5. 8 Semua lampu berfungsi dengan baik *

5. 9 Tidak ada mur/ baut roda yang longgar atau lepas *

5. 10 Semua roda dalam kondisi layak *

5. 11 Tekanan angin sesuai pada roda *

5. 12 Grill pelindung dalam keadaan baik *

5. 13 Persupensi dalam keadaan baik *

5. 14 Wheel choke/ ganjal ban ***

5. 15 Traffic cone *

5. 16 Rotary lamps *

5. 17 Handrail (Tank Truck) *

5. 18 Pump bracket (Keranjang Pompa) ***

5. 19 Grill proteksi belakang ***

5. 20 Others…
Note :
1. * = Daily
2. ** = Weekly
3. *** = Monthly
4. Original kept by HSE Department
5. Copy Kept by related contractor
6. Attached SIO, SILO, Certificate, Other related document
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PROJECT MANAGEMENT OFFICE

Equipment is not allowed to be used until Major Items has been closed

Equipment is allowed to be used while Minor Items to be closed

Equipment is allowed to be used, no findings

Inspected by: Checked by: Checked by: Checked by: Checked by:

Name : Name : Name : Name : Name :

Position : Operator Position : PM/SM Position : Inspector HSE Position : HE Coordinator Position : HSE Manager
Date : Date : Date : Date : Date :

Note :
1. * = Daily
2. ** = Weekly
3. *** = Monthly
4. Original kept by HSE Department
5. Copy Kept by related contractor
6. Attached SIO, SILO, Certificate, Other related document