contoh+form+inspectins++scaffolding

SCAFFOLDING INSPECTION CHECK LIST

LOCATION :SCAFFOLDING TYPE : GENERAL SCAFFOLD :

MAX LOAD :CONSTRUCTED : DATE :

NO ITEM TO BE INSPECTION OK NOK REMARK1 Apakah pipa standard perancah mempunyai

plat dasar2 Semua plat dasar pipa standard benar-benar kuat3 Apakah pipa standard tegak lurus/level4 Apakah standard mempunyai jarak yang tetap5 Apakah sambungan dipipa standard telah benar6 Apakah ledger level7 Apakah tarnsom level8 Apakah tinggi perancah benar (2 meter maksimal)9 Apakah perancah diikat pada tingkat/level yang

ke tiga10 Dan disetiap dua tingkat berikutnya11 Apakah bangunan perancah kokoh12 Jalan untuk akses tersedia dan terikat ditingkat

yang teratas13 Papan kayu untuk bekerja tersedia14 Lebar papan kayu minimal 40 cm15 Papan kayu aman dan terikat16 Apakah handrail tersedia17 Apakah perancah level & tegak lurus18 Apakah clamp pengaman sudah terpasang19 Apakah scaffolding aman untuk dipergunakan

DESCRIPTION :USER : INSPECTION BY :

Company Safety Dept. Rigging Dept. Date of Inspection

INSPECTION LIST FOR FIRE PREVENTIVE

Date :ELECTRICAL (MAIN OFFICE LINE)

NO ITEM OK NOK REMARK

1 Transformer 3 Pass

2 Main Panel

3 Sub Panel

4 Main Line

5 Sub Distributor Line

6 Main Circuit Breaker

7 Sub Circuit Breaker

8 Cable Condition

9 Sub Distribution Cable

10 Fuse

11 How Many panel

12 Position of Cable

13 Fire Extinguisher

Inspected By, Electrician, Engineering, Q.C,Safety

___________ ___________ ____________ ______________

c:\excel\form Inspection List

INSPECTION FIRE EQUIPMENT FOR PREVENTIVE

Size InspectionNo Location Type Kg/Lt Date Service Expired Weekly Monthly Remark

A Tool Room 1. CO2 6,8 Kg. 10/1/2001 10/1/2002 4/8/20022. DC 6 Kg. 10/1/2001 10/1/2002 4/8/20023. DC 6 Kg. 10/1/2001 10/1/2002 4/8/20024. DC 6 Kg. 10/1/2001 10/1/2002 4/8/2002

B Work Shop Wall 1. DC 6 Kg 10/1/2001 10/1/2002 4/8/20022. DC 6 Kg 10/1/2001 10/1/2002 4/8/20023. DC 6 Kg 10/1/2001 10/1/2002 4/8/2002

C Mechanic Room 1. Foam 9 Lt 10/1/2001 10/1/2002 4/8/20022. DC 6 Kg 10/1/2001 10/1/2002 4/8/20023. CO2 6,8 Kg 10/1/2001 10/1/2002 4/8/2002

D Ware House 1. Foam 9 Lt 10/1/2001 10/1/2002 4/8/20022. CO2 6,8 Kg 10/1/2001 10/1/2002 4/8/2002 Hose must be replace3. CO2 6,8 Kg 10/1/2001 10/1/2002 4/8/20024. DC 6 Kg 10/1/2001 10/1/2002 4/8/20025. DC 40 Kg 10/1/2001 10/1/2002 4/8/20026. DC 40 Kg 10/1/2001 10/1/2002 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

Size InspectionNo Location Type Kg/Lt Date Service Expired Weekly Monthly Remark

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.