PT.

SABAKO MITRA SURVINDO

Certi cation & Inspection Services

CLIENT : PT. KALIMANTAN ENERGI LESTARI

DESCRIPTION : FORKLIFT
ITEM No FL O1
LOCATION : AREA PT. KALIMANTAN ENERGI LESTARI
KALIMANTAN SELATAN
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 PT. SABAKO MITRA SURVINDO
Certi cation & Inspection Services

CERTIFICATION OF FORKLIFT

CONTENTS

1 CERTIFICATE OF INSPECTION

2 VISUAL INSPECTION REPORT

3 MPI AND LOAD TEST

4 SUPPORTING FOTO
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 CERTIFICATE OF INSPECTION
PT. SABAKO MITRA SURVINDO
Certi cation & Inspection Services
Doc. No. :

:
22/KELŲFL-SMS/VII/23

July 26, 2023

Rev
:0
: 1of 1
Date Page

CERTIFICATE OF INSPECTION

Owner PT Kalimantan Energi Lestari

Name of Equipment FORKLIFT
Manufacturer Caterpillar
Serial No M8C-70527
Item No FL 01
Model Diesel Forklift
Type DP25ND
Capacity 2500 Kg
Safe Working Load 2500 Kg
Fork Length 1070 mm
Year Of Built/Used 2010
Date Of lnspection July 24, 2023
Type Of Inspection Visual Inspection
Dimensional Check
NDT Inspection ( MPI )
Fungsional Test & Load Test
Applicable Code Permenaker 05/MEN/1985
ANSI B56
AWS D1.1
Location Of Inspection : Area PT Kalimantan Energi Lestari
South Kalimantan
Result Accepted with note

Expaired Date July 24, 2024

Balikpepạn, 126 July 2023

SABA
Dod IpdrawanAndung
Inspector TRA
SURVDO
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 SARA PT. SABAKO MITRA SURVINDO
TRASUVINDO Certi cation & Inspection Services

1 REPORT NO 22/KEL/FL-SMS/NI/23
2 NAME OF EQUIPMENT Forklift
3 CLIENT/USER PT Kalimantan Energi Lestari
4 DATE OF INSPECTION July 24, 2023
5 LOCATION OF INSPECTION : Area PT Kalimantan Energi Lestari
South Kalimantan

I. FORKLIFT DATA

1 ITEM NO : FL 01
2 SERIAL NO
3 MANUFACTURE Caterpillar
4 TYPE/ MODEL DP25ND/ Diesel Forklift
5 CAPACITY OF FORKLIFT 2500 kg
6 YEAR OF BUILD & USED 2010
7 FORK LENGTH : 1070 mm

8 ENGINE MANUFACTURE Caterpillar

- TYPE/MODEL : DP25ND/ Diesel Forklift
SERIAL NO. : M8C-70527

RPM, Kw, : NJA

9 FORK
- MANUFACTURE : N/A
TYPE/MODEL DP25ND
SERIAL No. : T18C-70527
CAPACITY 2500 kg
WEIGHT

10 MAST
MANUFACTURE : Caterpllar

TYPE/ MODEL : N/A

SERIAL NO. N/A
CAPACITY : 2500 Kg

- WEIGHT N/A

11 TIRE HANDLER
MANUFACTURE N/A
TYPE/ MODEL NJA
SERIAL NO. : NJA
CAPACITY : N/A
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 PT. SABAKO MITRA SURVINDO
Certi cation & Inspection Services

II. VISUAL INSPECTION

CONDITION
NO DESCRIPTION REMARK
GOOD NOT GOOD N/A
|Check of Lower Construction
|Acceptance Criteria ANSI B.56.6 & ANSI B56.1
-Truck, Chassis
- Horizontal Proper shaft
Out rigger
-Wheel Tire
Mast
- Chain Mast

Check of Upper Structure

|Acceptance Criteria ANSI B.56.6 & ANSI B56.1
- Main Frame
- Slew Drive
* Slew Motor
*SlewBrake
* Slew Gear Box & Oil State
Slew Clutch
* Hydraulic Hose & Connection
* Actuator Cylinder
-CounterWeight
- PTO

4 Check of Engine
JAcceptance Criteria ANSI B.56.6 & ANSI BS6.1
Exhaust System
* Manifold & Piping
*Silincer
* Heat Insulation
* Spark Arrester
- Intake System
* Air Cleaner Indicator
Turbo Charger
* Air Line/ Pipe
Engine Indicator
Oil Pressure
*Water Temp.Gauge
* Air Pressure Gauge
Amp. (current) Indicator
* RPM Indicator
-StarterMotor
- Cooling System
- Visual Appreance (Clean lines/oil leakage) No Leak
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 PT. SABAKO MITRA SURVINDO
MITRA SURVINDO Certi cation & Inspection Services

NO DESCRIPTION CONDITION
REMARK
GOOD |NOT GO0D N/A
5 Check of Hydraulic/Pneumatic System
|Acceptance Criteria ANSI B.56.6 & ANSI B56.1
Reservoir/Tank
- Hoses

-Filter
- Hydraulic Press. Gauge
- Pump/Compressor

- Cylinder & Rod

6 Check of Brake System

Acceptance Criteria ANSI B.56.6 & ANSI B56.1
- Hoist Brake

- Emergeny Brake

Boom Hoist Brake

- Travelling Brake

- Parking Brake

7 Check of ElectricalSystem
|Acceptance Criteria ANSI B.56.6 & ANSI B56.1
Circuit Breaker
- Wiring / Harness
- Battery & Compartment

-Charging System
Cable & Tray
- Panel Control

8 Check of Accessories structure & Operation Station

|Acceptance Criteria ANSI B.56.6 & ANSI B56.1
-Cabin
- Ladder
Hand Rail
- Services Acces.

WindshieldGlass / Frame
- Seat and cushion

- Door / Windows
-Lighting/Lamp
- Control lever

- ldenti cation

- Wiper

- AC / Fan
- Driving Control
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 PT. $ABAKO MITRA SURVINDO
TRA URVIND Certi cation & Inspection Services

INo CONDITION
DESCRIPTION REMARK
GOOD NOTGOOD N/A
Check of Safety Devices
Acceptance Criteria ANSI B.56.6 & ANSI B56.1
- Boom Back Limit Switch
- Load Indicator
Angle Indicator
- Radius Indicator
- Water Level Indicator
- Swing Alarm
Backward Alarm
Power Driven ESD Sys.
- Fire Extinguisher
- Warning Light
Anti Skid
Safety latch

10 Check of Fork and Lifting accessories

Acceptance Criteria ANSI B.56.6 & ANSI B56.1
Fork
Backrest frame
- Lock of Fork Handle
- Weld handle of Fork
- Jib Lifting
Weld handle of Jib Handle
- Man Basket
- Tire Handle
Note : according to the actual measurement results at the time of inspection

Length of Fork (L) 1070 mm

Center of Length Fork (D)
Height of Frame Fork (H) 500 mm
Thickness of Fork
Width of Fork

W
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 ABAKO PT. SABAKO MITRA SURVINDO
TRABURVDNDC Certi cation & Inspection Services

III. FUNCTIONAL TESTING

Acceptance Criteria ANSI B.56.6 & ANSI B56.1

NO OPERATING TESTING WITHOUT LOAD WITH LOAD

1 Fork Lifting operation It can be operated It can be operated
Lifting & Lowering Boom It was not availale It was not availale
Lifting Speed It can be operated It can be operated
4 LoweringSpeed It can be operated It can be operated
5 Limit Switch It was not availale It was not availale
6 Brake System lt can be operated It can be operated
7 Lighting System It was not availale It was not availale
8 Load & Angle Indicator It was not availale It was not availale
9 Safety Device It can be operated It can be operated

IV. LOADTESTING
Acceptance Criteria ANSI B.56.6 & ANSI B56.1

Test Load Actual Test

NO SWL (kg) Fork Length ( mm) Angle () Result
(kg) Load (kg)
After loadtest the we found
1 2500 1000 1000 1070
leaking on hydraulic sistem

Note: actual load test as per client requirementbecausewe not found any counter weight for
load 2500 kg

V. CONCLUSION
1. Based on the result of inspection above, we conclude that the forklift in good condition but any some leak on
hydraulic sistem and make the lift of fork down while operated, forklift must be maintenance and services.

2 The fork lift should be periodically inspection on July 24, 2024

Inspected by
PTSABAKO
MITRA SURVINDO

ABAVO

Dody Ihdrawan.A, SURVID

s

Lifting
Inspector Y
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 PT. SABAKO MITRA SURVINDO
Certi cation & Inspection Services

REPORT OF PROOF LOAD TEST

Report No. 22/KEL/FL-SMS/VII/23
I GENERAL DATA
- Client : PT Kalimantan Energi Lestari

Name of Equipment : Forklift

Manufacture : Caterpillar

- Type / Model : DP25ND/ Diesel Forklift

- Item Number : FL 01
Serial Number : -
Capacity of Fork Lift : 2500 kg

Date of Load Test : July 24, 2023

- Location of Inspection : Area PT Kalimantan Energi Lestari

II LOADTEST
Load Test Refer to ANSI B.56.6 & ANSI B56.1 of Forklift as follows :

Test Load Actual Test Load Fork Length Holding Time

NO SWL (kg) Result
(kg) (kg) ( mm (Minute)

After loadtest, we found leaking on

1 2500 1000 1000 1070 5
hydraulic system

II PHOTOOFLOADTEST

(
Tested By. Witnessed.

ADAKO
KELNnfa
ENERLESTARI
DodyJhdrawan:A
Lifting Inspector PT. KalimAntan Energi Lestari
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 PT. $ABAKOMITRASURVINDO
Certi cation & Inspection Services

PHOTOGRAPH OFINSPECTION

Sabako Mitra Survindo. PT

INSPECTION AND CERTIFICATION SERVICE
Phone : 0542-7251388 Fax :0542-770048
Emal:Infosabako.com OUCY

USER/OWNER
PECFED FOR THE TIUCK NECE
NAMEOFEQUPMENT :OPE LIFT
MANUFACTURE CATERPUun
TEMISERIAL
NUMDER:tL o
CAPACITYISW :2500 9
pwENSIONAL LfORE; tOọ nm
DATE hy 24.Qa3
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 PT. SABAKO MITRA SURVINDO
Certi cation & Inspection Services
MAGNETIC PARTICLE INSPECTION REPORT
|CLIENT : PT Kalimantan Energi Lestari Document NO
DESCRIPTION : Fork Forklift REPORT NO. : 22/KEL/FL-SMS/NI/23

SERIAL NUMBER DATE OF INSP : July 24, 2023

ITEM NUMBER : FL 01 LOCATION OF : Area PT Kalimantan Energi Lestari
INSP.

SURFACE :0AS WELDED

- SEQUENCES OF :O SURFACE
CLEANING
PREPARATION MACHINING TEST DAPPLY WHITECONTRAS
OBLASTING MAGNETIZATION
D WIREBRUSHING APPLY MAGNETICINK
O OTHER INSPECTION

PROCEDURE NO. : MPI-SMS-02 MAGNETIZATION : YOKE (S/N: 2875 /Parker )

ACC CRITERIA : AWS D1.1 & ASME SEC. V EQUIPMENT O COIL (S/N:346 / Parker)
METHOD : CONTINUOUS METHOD MAGNETIZATION : D AC
|APPLICATION : SPRAY ON WELD CURRENT DC
CHEMICALS :DCLEANER
(SKC-s) PERMANENT
CONTRAST(WCP-2) CALIBRATION :0 10|b(S/NCB-LD-E4.5
: )
MAGNETIC PARTICLE (7 HF) BLOCK 40 Ib (S/N:CB-LD-40LB)
O MAGNAGLO(14AM)
No
Result Typeo
Part of Observation Remarks
Accepted Rejected discontinuties
Critical area No Indication of Defect

= MPI Area

Note : MPI Performed Before and After Load Test

Inspęcted By:

SABAIO
DodyAndrawan.A.
ASNTNDT LVRAsUVi
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 PT. Kalimantan Energi Lestari
Sungai Durian
Kota Baru, Kalimantan Selatan.
KEE
KALIMANTAN
ENERGI LESTARI

SERTIFIKATKELAYAKAN PENGGUNAAN PERALATAN

Nomor:
Direktur Jenderal Mineral dan Batubara berdasarkan:
1. Undang-undang Nomor 1 Tahun 1970 tanggal 12 Januari 1970;
2. Undang-undang Nomor 4 Tahun 2009 tanggal 12 Januari 2009;
3. Peraturan Pemerintah Nomor 19 Tahun 1973 tanggal 14 April 1973;
4. Peraturan Pemerintah Nomor 55 Tahun 2010 tanggal 5 Juli 2010;
5. Keputusan Presiden Republik Indonesia Nomor 151/M Tahun 2013 tanggal 12 Desember 2013;
6. Keputusan Menteri Pertambangan dan Energi No. 555.k/26/M.PE/1995 tanggal 22 Mei 1995;
7. Peraturan Menteri Energi dan Sumber Daya Mineral Nomor 13 Tahun 2016 tanggal 16 Mei 2016;
8. Pereturan Menteri Energi dan Sumber Daya Mineral Nomor 38 Tahun 2014 tanggal 30 Desember 2014;
9. Keputusan Direktur Jenderal Mineral dan Batubara Nomor 687 K/70/DJB/2014 tanggal 21 Juli 2014;
10. Hasil pemeriksaan dan pengujian oleh Perusahaan Jasa Inspeksi Teknik PT Sabako Mitra Survindo,
tanggal 24 July 2023 dan Laporan Dokumen Hasil Pemeriksaan, nomor :22/KEL/FL-SMS/NI/23

PESAWAT ANGKAT DAN ANGKUT

Pemilik / Pemakai : PT Kalimantan Energi Lestari

Lokasi digunakan : Area PT Kalimantan Energi Lestari,

Kalimantan Selatan.

dengan keterangan data-data peralatan terlampir,

dinyatakan dapat di gunakan dengan catatan yang terlampir pada laporan perneriksaan dan sesuai dengan
ketentuannya.
Serti kat ini berlaku sampai dengan tanggal : 24 July 2024

Diterbitkan di : Kota Baru, Kalimantan Selatan

Tanggal : 26 July 2023

KEPALA TEKNIK TAMBANG

PT KALIMANTAN ENERGI LESTARI

KELnAMANT
GURITNOS.
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 Lampiran Serti kat Kelayakan Penggunaan Peralatan KPP)
Nomor
Tanggal

No. 1. Berdasarkan Laporan Hasil Pemeriksaan No. 22/KEL/FL-SMS/Vi/23

denganketerangan:
1. Jenis Pesawat
:Forklift
2. No. Seri /No. Item : M8C-70527
3. Tipe / Model DP25ND/ Diesel Forklift
4. Pabrik Pembuat :
Caterpillar
5. Kapasitas Orisinal 2500 Kg
6. Penggunaan Mengangkat dan Memindahkan Material / Barang
7. Tahun dibuat
8. Referensi/Standar :ANSI B56, AWS D1.1

Pengujian beban yang dilakukan

Beban Beban Kerja Panjang

No Waktu
Uji Aman (SVWL) Fork Keterangan Pengujian
(menit)
(kg) (kg) (mm)

1 1000 2500 1070 5 (100% Dari SWL)

Dapat di gunakan dengan catatan dan ketentuan yang terlampir dan dengan mengacu tabel beban kerja aman di
atas dengan ketentuan:
PT Kalimantan energi lestari bertanggung jawab sepenuhnya atas keselamatan operasi Pesawat Angkat
tersebut;
- Operator yang mengoperasikan harus memiliki Surat Izin Operasi (SIo) dan Rigger yang memiliki
serti kat;
- Serti kat Klayakan Penggunaan Peralatan ini dapat ditinjau kembali apabila dikemudian hari terdapat
hal-hal yang menyebabkan Pesawat Angkat tidak layak dan tidak aman untuk dioperasikan

KEPALA TEKNIK TAMBANG

PT KALIMANTAN ENERGI LESTARI

KEL nyfufaaas
GURITNO S.

1
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