QUARTERLY INSPECTION REPORT
WEBBING SLING
Period : COLOR PERIOD
SWL Condition Date
No No Registrasi Length Brand Location Remarks
( Ton ) Good Bad Inspection
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HES INSPECTOR USER
QUARTERLY INSPECTION REPORT
CHAIN BLOCK & LEVEL BLOCK
Period : COLOR PERIOD
Condition
Load Hand Hock Safety Date Remarks
N0 No Registrasi SWL Manufacture Gear Of Location
Inspection
Chain Chain Latch Chain
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HES INSPECTOR USER
QUARTERLY INSPECTION REPORT
SHACKLE
Period : COLOR PERIOD
Diameter ( mm ) SWL Condition Date Remarks
Period : January - AprilNo
2011
Registrasi Location
Body Pin ( Ton ) Pin Body Nut/Screw Pin Inspection
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HES INSPECTOR USER
INSPECTION REPORT
WIRE SLING
Period : COLOR PERIOD
Bentangan Kerusakan Wire Panjang Ukuran Date
No No Registrasi SWL (Ton) Brand Diameter Location Remarks
Good Bad Good Bad (M) Inspection
( Inchi )
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HES INSPECTOR USER
INSPECTION REPORT
ELECTRIC GRINDING/HAND TOOLS
Period : COLOR PERIOD
Condition Inspection
No No Registrasi Brand Serial No Size Location Remarks
Good Bad Date
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HES INSPECTOR USER
INSPECTION REPORT
PORTABLE ELECTRICAL TOOLS
Period : COLOR PERIOD
Switch Otomatis
Tidak Ada Retak Name Plate Pegangan
Kembali Pada Tutup Pengaman RPM Maximum Inspection
No Nomor Registrasi Merek Pada Rangka Terlihat Jelas Handle Aman Location Remarks
Posisi Date
Good Bad Good Bad Good Bad Good Bad Good Bad Good Bad
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HES INSPECTOR USER
FULL BODY HARNESS INSPECTION REPORT
Period : COLOR PERIOD
Kapasitas
Kondisi D - Ring ( Tali Shock Absorber
Angkat Penyetel Inspection
No Nomor Registrasi Manufacture Belt/Tali Gantungan ) ( Tali Penahan ) Location Remarks
Terlihat Jelas Date
Good Bad Good Bad Good Bad Good Bad Good Bad
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HES INSPECTOR USER
QUARTERLY INSPECTION REPORT
Coating Tools and Equipment
Period : COLOR PERIOD
Condition Inspection
No No Registrasi Unit Number Model/Type User/Foreman Location Remarks
Good Bad Date
Dilaporkan oleh, Diketahui Oleh
HES INSPECTOR HES SUPERVISOR
INSPECTION REPORT
ELECTRIC GRINDING / HAND TOOLS
Period : COLOR PERIOD
Condition Inspection
No No Registrasi Brand Size User / Foreman Location Remarks
Good Bad Date
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HES INSPECTOR USER
INSPECTION REPORT
WELDING ROD HEATER
Period : COLOR PERIOD
Condition Inspection
No No Registrasi Model Size Tag Number Location Remarks
Good Bad Date
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HES INSPECTOR USER
QUARTERLY INSPECTION REPORT
EXTENSION CABLE
Period : COLOR PERIOD
Condition Inspection
No. No Registrasi Location Remarks
Good Bad Date
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HES INSPECTOR USER
QUARTERLY INSPECTION REPORT
LEVEL BLOCK & CHAIN BLOCK– HOOK
Period : COLOR PERIOD
SWL Manufacturer / User / CONDITION Inspection
No No Registrasi Location Remarks
(Ton) Type/Specification Foreman Good Bad Date
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HES INSPECTOR USER
QUARTERLY INSPECTION REPORT
SHACKLE
Period : January - April 2011 COLOR PERIOD
:
Januar Diameter (mm) Condition Inspection
No Registrasi SWL (Ton) Location Remarks
y- Body Pin Date
April Good Bad
2011
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HES INSPECTOR USER
QUARTERLY INSPECTION REPORT
SLING
Period : COLOR PERIOD
SWL Condition
No No Registrasi Length Brand Location Inspection Date Remarks
(Ton) Good Bad
Dilaporkan oleh, Diketahui Oleh
HES INSPECTOR USER
CHAIN BLOCK – HOOK INSPECTION REPORT
Period : COLOR PERIOD
Condition
SWL Manufacturer / Inspection
No No Registrasi Load Hand Safety Gear of Location Remarks
(Ton) Type/Specification Hook Date
Chain Chain Latch Chain
Dilaporkan oleh, Diketahui Oleh
HES INSPECTOR HES SUPERVISOR
INSPECTION REPORT
SLING
Period : COLOR PERIOD
SWL Condition Inspection
No No Regsitrasi Sling ID Length Brand Location Remarks
(Ton) Good Bad Date
Dilaporkan oleh, Diketahui Oleh
HES INSPECTOR USER
INSPECTION REPORT FIRE EXTINGUISHER
Period : COLOR PERIOD
Alat Safety Pin Slang Bodi APAR
Pemadam Api Pressure di terpasang di terpasang bersih / tidak
Ringan posisi Hijau tempatnya dan kuat dan rusak atau Lokasi Tanggal inspeksi Di Inspeksi oleh
No Nomor Registrasi Tipe Ukuran segel tidak terakhir Keterangan
Alas/Box rusak kondisi baik. berkarat.
Good Bad Good Bad Good Bad Good Bad Good Bad Name Signature
Dilaporkan oleh, Diketahui Oleh
USER
HES INSPECTOR
INSPECTION REPORT
REGULATOR TABUNG GAS
Period : COLOR PERIOD
Gauges ( Pressure ) Hoses Valves Nozzle Inspection
No No Regsitrasi Brand Location Remarks
Good Bad Good Bad Good Bad Good Bad Date
Dilaporkan oleh, Diketahui Oleh
HES INSPECTOR USER
INSPECTION REPORT VEHICLES
Period : COLOR PERIOD
MERK ASSET NO.
MODEL/ TYPE SERIAL NO.
TH. PEMBUATAN LOKASI
Period : January - April 2011
HASIL PEMERIKSAAN
NO. ITEM YANG DIPERIKSA CATATAN PEMERIKSA
BAIK RUSAK HILANG
1 KONDISI MESIN
2 KONDISI BODY
3 LAMPU DEKAT / JAUH
4 LAMPU SIGN DEPAN/ BELAKANG
5 KONDISI BAN
6 BAN CADANGAN
7 KONDISI REM
8 ALARM/ KLAKSON
9 KUNCI RODA
10 SAFETY BELT
11 KOTAK P3K
12 KACA SPION
13 ARM WIPER
14 AC + RADIO TAPE
REKOMENDASI :
LAYAK & AMAN DIOPERASIKAN :
TIDAK AMAN DIOPERASIKAN :
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HES INSPECTOR USER
QUARTERLY INSPECTION REPORT
HOOK
Period : COLOR PERIOD
Condition
Load Hand Hock Safety Date Remarks
N0 No Registrasi SWL Manufacture Gear Of Location
Inspection
Chain Chain Latch Chain
Dilaporkan oleh, Diketahui Oleh
HES INSPECTOR USER
INSPECTION REPORT
EYE WASH
COLOR PERIOD
Period :
Level Air Body Berfungsi Cover Atas Inspection
No No Registrasi Brand Location Remarks
Good Bad Good Bad Good Bad Good Bad Date
Dilaporkan oleh, Diketahui Oleh
HES INSPECTOR USER