Page 1 of 3

VEHICLE - PRE-MOB INSPECTION REPORT

Applies to Sedan, Station Wagon, Minibus, Pick Up and Canopy

Equip. No. : Type : Model : Brand :

License Plate No :
Serial No. : Km/Hourmeter : Service Date :

Inspected by : Date : Location : Owner :

d
Description to be Checked

oo
Remarks

/A
oo

N
G

o
N
Documentation Operator and Equipment
1 Today's Pre-Trip Inspection Original Copy Available on Unit
2 Original Manufacturer Name Plate with Serial Number Year of Manufacture:
3 Original or a Copy of Operation Manual Book Matches Unit Type and Series
4 SOP - Standard Operating Procedure Based on OEM Operation Manual Book
5 Operator/Driver Government Driving Licence Expiry :
6 Company Operator/Driver Permit Expiry :
7 STNK - Vehicle Document Expiry :
8 KEUR - Inspection Book Expiry :
9 Nota Pajak - Tax Expiry :
10 Kartu Kendali - Traffic Police Document Expiry :
11 Riau BM Police Number Plate Front - Rear Expiry :
12 Company ID Number, Company Logo Correct Size, Minimum 10 Cm Height, Visible
13 Official SAMSAT Letter for NON BM (Surat Tanda Lapor Kendaraan Bermotor)
14 Official DLLAJR Letter for NON BM (Surat Izin Operasi Angkutan)
15 Official DLLAJR Letter (Rekomendasi Izin Angkutan Karyawan)

Mandatory Safety Inspections and Devices

1 Back-Up Light Adequate Illumination, Function Test
2 Horn Easily Operated From Inside Driver's Cabin, Easy to Hear
Seat Belts for Driver, Operator, Passenger(s)
3
Good Condition, Properly, Mounted with OEM Hi-Tensile Bolts
4 All Seats, Cushions Securely Mounted, Ergonomically Good Condition, Not Torn Open or Dilapidated
Special for Canopy ROPS To Be Constructed According to Established Safety Standards with Engineered
5
Drawings Available If Required
Special for Canopy Seats Cushions Securely Mounted, Ergonomically Good Condition, Not Torn Open or
6
Dilapidated, Head Rest Cushions on Back of Seats to Protect Passenger's Heads
7 Parking Brake Function Test
8 Service Brakes Front and Rear Properly Adjusted, No Air, Vacuum or Fluid Leaks, Test Function
Axle Wheel Bearing Lubrication
9 Front and Rear Axle Hubs to Be Properly Lubricated and No Leaks, No MISSING COVERS / CAPS on
Grease Type Hubs
Power Steering System Check All Steering Linkages, No Loose Ball Joints, Lubricated Properly, Not
10
Loose, No Excess Freeplay, No Loose Mounting Bolts, Function Test
Tire and Wheel Condition, No Broken-Missing Lug Nuts,Tread Depth Minimum 3mm, No Recaps /
11 Retreads / Vulcanized Tires, Correct Rotation, Recommend Front and Rear Tread "All-Terrain" Pattern on
P/U's
12 Head Lights High-Low Beam Function Correctly
13 Interior Lights Adequate Illumination, Function Test
14 Rear Combination Lights Adequate Illumination, Function Test
15 Front Combination Lights Adequate Illumination, Function Test
16 Electrical Wiring Condition, Fuse Block All Splices Insulated, No Bare Wires
Side mounted Left and Right Door Mounted Rear View Mirrors
17
Not Loose, Clear Unobstructed Vision, Functions Properly
Internal Centrally Mounted Rear View Mirror
18
Not Loose, Clear Unobstructed Vision, Functions Properly
All Window Glass / Windshield Glass Totally Clear, No Film or Stickers Blocking Vision.
19
Units with OEM Window Tint Will Require Approval by Relevant CPI Authorities.
20 Windshield Wipers and Washer Wiper Blades Not Perished, Test Function
21 Doors, Door Locks, Door Handles, Left - Right, Outside and Inner Function Test
22 Safety Triangles Two Units In Good Condition, Reflective So As Visible at Night
Fire Extinguisher Mounted on a Proper Bracket, Easily demounted, Accessible. Current and Valid
23
Quarterly Inspection Sticker with a valid Inspection Cycle Tag. Size ½ Kg to 1Kg
24 First Aid Kit Clean, Tidy, Completely Full
Safety Guards and Covers
25
All In Place, Not Loose, None Missing, Not Modified, Remain within OEM Specs
26 Driver Monitoring System Refer to CPI Contract, Perform Function Test

Body
1 Body Condition Good Paint and General Appearance, No Excess Damage, No Rust

Cabin and Interior

1 Cabin Interior Condition Clean, No Rubbish, Good Housekeeping
Dashboard Indicators Gauges For Fuel, Hours, Kms, Odometer, Temperature, Brake Air Pressure,
2
Alternator, Battery Voltmeter, Battery Charging System, etc, All Operating Properly.
 Page 2 of 3
VEHICLE - PRE-MOB INSPECTION REPORT
Applies to Sedan, Station Wagon, Minibus, Pick Up and Canopy

Equip. No. : Type : Model : Brand :

License Plate No :
Serial No. : Km/Hourmeter : Service Date :

Inspected by : Date : Location : Owner :

d
Description to be Checked

oo
Remarks

/A
oo

N
G

o
N
3 Steering Wheel Not Loose, Controls Vehicle Properly, Function Test
4 Combination Switch, Light Switch, Switches, Knobs Test Function
5 Electrical Wiring Condition, Fuse Block All Splices Insulated, No Bare Wires
6 Cabin Air Conditioner, Fan Function Test

Main Frame and Main Chassis

1 Main Chassis, Frame Good Condition, Straight, Not Bent, No Cracks, No Uncertified Welding Repairs

2 Sub Chassis, Sub Frame Good Condition, Straight, Not Bent, No Cracks, No Uncertified Welding Repairs

3 Front and Rear Bumper Bars Rounded Corners, No Sharp Edges, Not Loose, Properly Mounted
4 Springs, Front and Rear, Suspension System Straight, Not Bent, No Loose Pins or Bushings
5 Fuel Tank No Loose Mounts, Filler Cap, Properly Secured, No Leaks

General Hydraulics, Fluids, Fuel Lines, Hoses

1 All Fuel Hoses and Lines Properly Secured, No leaks
2 All Hydraulic Power Steering Hoses and Hydraulic Lines Properly Secured, No Leaks
Power Steering Pump and Tank
3
No Loose Mount Bolts, No Loose Belt(s), No Leaks, No Excess Noise, Filler Cap Properly Secured
4 Fuel Tank No Loose Mounts, No Leaks, Proper Filler Cap
5 Air Tank(s) No Leaks, No loose Mounts

Engine - Transmission
1 Engine Clean Appearance, No Leaks, No Defective Mounts, Observe Performance
2 Engine Dipstick Easy to read, Oil Level Adequate
Battery, Battery Covers, Battery Mounting
3 Battery Terminals Clean, Optional Battery Disconnect Switch, Test Function, No Loose or Corroded
Cables-Terminals, Battery Hold-Downs in Place, Clean Battery Box, No Loose Mounts
4 Starter Motor Test Function, Adequate Cranking Strength, No Bad Noises or Overheating
Alternator
5
Observe Charging Function, No Bad Noises or Overheating, No Loose Mounts, No Loose Belts
6 Cooling System Radiator, Water Pump and Hoses, No Leaks, No Perished Hoses
7 V-Belts or Serpentine Belts Not Loose, Not Squealing, Not Cracked
8 Exhaust System Check Pipe, Muffler, No leaks, Not Loose
9 Transmission PTO and Auxiliary Transmisson No Leaks, Observe a Function Test
Drive Shafts, Propeller Shafts, U-Joints, Center Carrier Bearing
10
Properly Greased, No Leaks, All Mountings Tight, No Loose Components
11 Clutch No Smoke or Slipping, Observe a Function Test
12 Differentials Front and Rear No Leaks, All Mountings Tight, Nothing Loose

Servicing and Maintenance

1 Maintenance Schedule - PM and PdM Service Records Available

Others
1
2
3

Comments
Good = Good condition, able to be operated in all CPI areas
Driver (Name and Badge) : Signature : No Good = Broken, Malfunction, Repair or Replace
N/A = Not Applicable
Inspected by: Acknowledged by TF and CPI :
The undersigned hereby accept and agree that this equipment is
"OK" and safe for operation. Menerima dan Menyetujui bahwa Alat
ini sudah "OK" dan aman untuk dioperasikan.

SIGNATURE, Date

TF CEM TF HES
Contractor's Name :
LJWard/DFB 11 Nov '10
 No : BPAC-FR-OHSE-024 Page 3 of 3

Tgl. Terbit : 01 September 2022

FORM COMMISSIONING INSPECTION BUS KARYAWAN Revisi :0
Halaman :1

No Unit : Type : KM/HM :

Merk : Jenis Unit : No. Pol :

Tanggal : Site : Tahun Buat :

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Materi Pengecekan Catatan

ba ida
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Ti s
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Status
1 New Commissioning Layak

2 Re - Commissioning Tidak Layak

Mandatory Safety Inspections dan Kelengkapan

1 Alarm mundur

2 Strobe light terpasang

3 Reflective tape terpasang pada semua sisi unit.

4 Radio komunikasi dua arah

5 No lambung unit

6 Lampu mundur

7 Lampu Rem

8 Lampu utama (jauh dan dekat)

9 Lampu sein kiri - kanan (depan dan belakang)

10 Lampu indikator di dashboard (jika ada yang tidak aktif lampirkan di catatan)

11 Klakson

12 Safety belt

13 Rem parkir

14 Rem depan dan belakang keseluruhan (periksa brake shoe dan stel)

15 Steering system, (kondisi komponen stir) jika ada kerusakan lampirkan di catatan

16 Kondisi ban secara keseluruhan (jika ada kerusakan lampirkan di catatan)

17 Kondisi kabel2 (kelistrikan)

18 Kaca spion kiri dan kanan

19 Kaca spion tengah

20 Kondisi kaca depan, kaca pintu dan kaca belakang

21 Kipas air (wiper blade)

22 Kondisi pintu, kunci pintu, handel pintu kiri dan kanan

23 Segi tiga pengaman (safety triangle)

24 APAR (alat pemadam kebakaran) kapasitas 1 kg

25 Kotak P3K

26 Dongkrak dan Kunci roda

27 Buggy Whip

Rangka

1 Kondisi rangka utama (keseimbangan, retak dan patahan)

2 Kondisi rangka penunjang

3 Bumper depan dan belakang

4 Per depan dan belakang

Mesin dan Transmisi

1 Kondisi kebersihan mesin

2 Kondisi stick oli (tidak bengkok, patah dan level oli terbaca)

3 Kondisi Aki, air aki, tutup aki dan penyangga

4 Kondisi dinamo start dan Kondisi dinamo cas

5 Sistim pendingin, radiator, pompa air dan slang/saluran air

6 Kondisi dan ketegangan V-belt

7 Saluran buang, pipa dan knalpot

8 Kondisi Transmisi (perpindahan gigi)

9 Kondisi sambungan Transmisi ke gardan

10 Kondisi kopling

11 Kondisi gardan

Lain-lain

1 4x4 (4WD)

2 warna putih (white) atau warna terang

3 Tow point / penderek terpasang dengan memadai.

Inspeksi oleh : Diketahui oleh Menerima dan Menyetujui bahwa Alat ini sudah Di uji
Kelayakan.
Tanda Tangan Tanggal

OHSE Dept. Plant Dept. Inspector Commissioning Penanggung Jawab Operasional

Kepala Teknik Tambang