Contoh+Form+Inspectins++Scaffolding

SCAFFOLDING INSPECTION CHECK LIST LOCATION SCAFFOLDING TYPE MAX LOAD CONSTRUCTED

: :

GENERAL SCAFFOLD :

:

DATE

:

NO ITEM TO BE INSPECTION 1 Apakah pipa standard perancah mempunyai plat dasar 2 Semua plat dasar pipa standard benar-benar kuat 3 Apakah pipa standard tegak lurus/level 4 Apakah standard mempunyai jarak yang tetap 5 Apakah sambungan dipipa standard telah benar 6 Apakah ledger level 7 Apakah tarnsom level 8 Apakah tinggi perancah benar (2 meter maksimal) 9 Apakah perancah diikat pada tingkat/level yang ke tiga 10 Dan disetiap dua tingkat berikutnya 11 Apakah bangunan perancah kokoh 12 Jalan untuk akses tersedia dan terikat ditingkat yang teratas 13 Papan kayu untuk bekerja tersedia 14 Lebar papan kayu minimal 40 cm 15 Papan kayu aman dan terikat 16 Apakah handrail tersedia 17 Apakah perancah level & tegak lurus 18 Apakah clamp pengaman sudah terpasang 19 Apakah scaffolding aman untuk dipergunakan

DESCRIPTION : USER : Company

OK

: NOK

REMARK

INSPECTION BY : Safety Dept.

Rigging Dept.

Date of Inspection

INSPECTION LIST FOR FIRE PREVENTIVE Date

: ELECTRICAL (MAIN OFFICE LINE)

NO 1 2 3 4 5 6 7 8 9 10 11 12 13

ITEM

OK

NOK

REMARK

Transformer 3 Pass Main Panel Sub Panel Main Line Sub Distributor Line Main Circuit Breaker Sub Circuit Breaker Cable Condition Sub Distribution Cable Fuse How Many panel Position of Cable Fire Extinguisher

Inspected By, Safety

___________

Electrician,

___________

Engineering,

____________

Q.C,

______________

INSPECTION FIRE EQUIPMENT FOR PREVENTIVE No

Location

Type

Size Kg/Lt

Inspection Weekly Monthly

Date Service

Expired

6,8 Kg. 6 Kg. 6 Kg. 6 Kg.

10/1/2001 10/1/2001 10/1/2001 10/1/2001

10/1/2002 10/1/2002 10/1/2002 10/1/2002

4/8/2002 4/8/2002 4/8/2002 4/8/2002

6 Kg 6 Kg 6 Kg

10/1/2001 10/1/2001 10/1/2001

10/1/2002 10/1/2002 10/1/2002

4/8/2002 4/8/2002 4/8/2002

Remark

A

Tool Room

1. CO2 2. DC 3. DC 4. DC

B

Work Shop Wall

1. DC 2. DC 3. DC

C

Mechanic Room

1. Foam 2. DC 3. CO2

9 Lt 6 Kg 6,8 Kg

10/1/2001 10/1/2001 10/1/2001

10/1/2002 10/1/2002 10/1/2002

4/8/2002 4/8/2002 4/8/2002

D

Ware House

1. Foam 2. CO2 3. CO2 4. DC 5. DC 6. DC

9 Lt 6,8 Kg 6,8 Kg 6 Kg 40 Kg 40 Kg

10/1/2001 10/1/2001 10/1/2001 10/1/2001 10/1/2001 10/1/2001

10/1/2002 10/1/2002 10/1/2002 10/1/2002 10/1/2002 10/1/2002

4/8/2002 4/8/2002 Hose must be replace 4/8/2002 4/8/2002 4/8/2002 4/8/2002

E

Power House

1. DC

6 Kg

10/1/2001

10/1/2002

4/8/2002

F

Roll Machine

1. DC

6 Kg

10/1/2001

10/1/2002

4/8/2002

c:\excel\form Inspection List

INSPECTION FIRE EQUIPMENT FOR PREVENTIVE No

Location

Type

Size Kg/Lt

Date Service

Expired

Inspection Weekly Monthly

G

Gantry Crane I

1. DC

6 Kg

10/1/2001

10/1/2002

4/8/2002

H

Kitchen Room

1. DC

6 Kg

10/1/2001

10/1/2002

4/8/2002

I

Personnel Dept.

1. CO2

6,8 Kg

10/1/2001

10/1/2002

4/8/2002

J

Accounting Dept.

1. CO2

4,4 Kg

10/1/2001

10/1/2002

4/8/2002

K

Reception Room

1. CO2

4,4 Kg

10/1/2001

10/1/2002

4/8/2002

Inspected By,

Inspected By,

_________ HSE Dept.

_______________ Ware House Dept.

c:\excel\form Inspection List

Remark