15_FORM Obyek Wisata

PENILAIAN PEMERIKSAAN KESEHATAN LINGKUNGAN (INSPEKSI SANITASI) OBYEK WISATA(PENINGGALAN SEJARAH, TAMAN REKREASI, WISATA WISATA ALAM, DLL

1. Nama oby! "#$a%a

& '''''''''''''''''.

. Aama%

& '''''''''''''''''.

*. Nama P+oa

& '''''''''''''''''.

-. Ta+a  m/#!$aa+

& '' '''''''''''''''''.

0. a. B/# %a+a 2 aa !o%a! 3 4 (!oom (!oom -, a+ #+!a/a+ #+!a/a+ +#a# (!oom (!oom 0) 5+%5! !omo++ +#a#a+ ya+ $$5a#.  b. S!o/ (!oom 6) aaa7 bobo% (!oom (!oom *) #!a#!a+ +a+ +#a# (!oom 0) 0)  aa !omo++ +#a#a+ ya+ $$5a# (!oom (!oom -) c.`Setap variable memiliki nilai maksimum 10 dan nilai minuman 0

 No

2ARIABEL UP UPAYA

BOBOT

1 I



*

1. #+!5+a+ 8 7aama+

9

II

KOMPONEN YANG DINILAI -

 NILAI

SKORE

0

6

UMUM

3 3

4 b/$#7 4 %#a! %/aa% +a+a+ a#/  3.....4 a#/ #mba7 m+a#/ +a+ a+:a/ 

*

3

-

*

;ASILITAS SANITASI 1. A#/ b/$#7

. To To#% 5m5m

16

16

4 %/$#a +a+  <5ma7 ya+ :5!5 3......4 mm+57# /$ya/a%a+ =#$#!  3......4 %/$#a !/a+ ya+ :5!5 ( m#+ 1 !/a+ 5+%5! %#a /a#5$ >m) 3 4 b/$#7 a+ %/#7a/a 3 4 %o#% #75b5+!a+ +a+ $a5/a+ a#/ !o%o/ !o%a a%a5 $%#: %a+!  3 4 <5ma7 %o#% $bb & ? U+%5 U+%5! ! $% $%#a #a 9>  +5+<5+ "a+#%a 1  b5a7 > 1>>  +5+<5+ /#a 1  b5a7
* *

* *





3

*. Pmb5a+a+ a#/ #mba7

-. Pmb5a+a+ $ama7

III

16

1-

4 #a!5!a+ +oa7a+ $+#/# a%a5 +oa7a+  /!o%aa+ 3 4 #$a5/!a+ ma5# $a5/a+ %/%5%5, !a a#/ a+ a+:a/  3 4 %/$#a <5ma7 %ma% $ama7 ya+ :5!5 m#+ 1 b5a7 5+%5! m 3 4 !5a% %a7a+ !a/a% !a a#/, /m5!aa+ 7a5$ a+ /a%a, b/+5%5 3 4 %/$#a TPS ya+ mm+57# $ya/a% 3......4 +a+!5%a+ $ama7 a/# TPS ! TPA m#+ * 7a/# $!a#



3

6

6

*

*

 

LAIN?LAIN 1. Sa/a+a +y557a+

. Sa/a+a8=a$##%a$ !$7a%a+

*. Aa% maam !ba!a/a+

TOTAL BOBOT

1

1

9

100

4 %/aa% %a+a?%a+a $a+#%a$#($oa+,  o$%/,) 3......4 %/$#a aa% +/a$ $5a/a 5+%5! mmb/#!a+  +y557a+8+/a+a+ 3 4 T/$#a  o#!#+#!8baa#  +oba%a+ 3......4 %/$#a m#+ 1 !o%a! P*K ya+ b/#$# oba%? oba%a+ $/7a+a 3 4 %/$#a aa% maam !ba!a/a+ ya+  b/=5+$# +a+ ba#! a+ m5a7 #
-

6

-

6

-

TOTAL SKORE

......,''''., >'.. M+%a75#, P+a+5+
P%5a$ 8 Pm/#!$a

( ................................................. )

( .................................................. )

PETUNJUK PEGISIAN ;ORMULIR DAN PENENTUAN LAIK SEHAT OBYEK WISATA (PENINGGALAN SEJARAH, TAMAN REKREASI, WISATA ALAM, DLL )

1. Komo++ ya+ #+#a# (!oom -) Aab#a !+ya%aa+ ya+ aa %#a! mm+57# /$ya/a%a+ $baa#ma+a %/:a+%5m aa !omo++ ya+ #+#a#, ma!a +#a#+ya aaa7 > (+o), $ba#!+ya aab#a mm+57#  /$ya/a%a+ ma!a +#a#+ya aaa7 $b$a/ +#a# ya+ %/:a+%5m aa !oom 0. . 2a/#ab 5aya (!oom ) S%#a ba#a+ a%a5 !#a%a+ a/# @a/#ab 5aya mm##!# +#a# a+%a/a (+o) ama# +a+ 1>>. *. S!o/ (!oom 6) S!o/ aaa7 /!a#a+ a+%a/a bobo% (!oom*) +a+ +#a# ya+ #/o7 (!oom 0) KESIMPULAN HASIL PENILAIAN PEMERIKSAAN KESEHATAN LINGKUNGAN OBYEK  WISATA ( PENINGGALAN SEJARAH, TAMAN REKREASI,WISATA ALAM, DLL ) 1. Oby! "#$a%a #+ya%a!a+ LAIK SEHAT aab#a mm/o7 +#a# $!5/a+?!5/a++ya 60  +a+ :a%a%a+ 5+%5! ma$#+?ma$#+ @a/#ab 5aya aaa7 $/%# %ab b/#!5% &

2ARIABEL UPAYA I

II

III

> 

60

6>