Nomor Formulir 022-PK-GKJ-SMK3LL

PEMERIKSAAN Tanggal terbit 01 Juni 2016

KENDARAAN Tanggal efektif 01 Juli 2016
GATRA KALTIM JAYA Revisi 00

No. Unit / Plat : ................................. Tanggal : .................................

KM : ................................. Nama Pengemudi : .................................

KONDISI / CONDITION
KETERANGAN /
No KETERANGAN / DESCIPTION BAIK/ JELEK/
N/A REMARKS
GOOD BAD
1 KEADAAN BAN / TYRES CONDITION
1.1 BAN DEPAN / FRONT TYRES
1.2 BAN BELAKANG / REAR TYRES
1.3 BAN CADANGAN / SPARE TYRES
2 KACA / MIRROR / WINDSHIELD
2.1 KACA SPION (L/R) WING MIRROR
2.2 KACA SPION DALAM / REAR VIEW MIRROR
2.3 KACA DEPAN / WINDSHIELD
3 PERALATAN / TOOLS
3.1 DONGKRAK + HANDEL / JACK +HANDLE
3.2 KUNCI BAN / WHEEL WRENCH
4 LAMPU-LAMPU / LIGHTING SYSTEM
4.1 LAMPU KECIL / DIM LIGHT
4.2 LAMPU BESAR / HEAD LIGHT
4.3 LAMPU BELAKANG / TAIL LIGHT
4.4 LAMPU RUANGAN / INTERIOR LIGHT
4.5 LAMPU MUNDUR / REVERSING LIGHT
4.6 LAMPU REM / BREAKE LIGHT
4.7 LAMPU REATING / SIGNAL LIGHT
4.8 LAMPU TANDA DARURAT / EMERGENCY SIGNAL LIGH
5 STNK / CAR REGISTER
6 PENANGKAPAN BARA / SPARK ARRESTOR
7 TEMPAT DUDUK / SEATS
8 SABUK PENGAMAN / SEAT BELT
9 KOTAK OBAT / FIRST AID KIT
10 PEMADAM API RINGAN / HAND FIRE EXTINGUISHER
11 KLAKSON / HORN
12 KUNCI PINTU SISTEM / DOOR LOCKING SYSTEM
13 PENGHAPUS KACA / WIPERS

14 POMPA WIPER / WATER PUMP FOR CLEANING WINDSH

Catatan :
..................................................................................................... Tertanda,
.....................................................................................................
.....................................................................................................
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*WAJIB DIISI SETIAP HARI OLEH DRIVER DIAWAL SHIFT. Pengemudi
 PEMERIKSAAN KENDARA
CATATAN

NO KETERANGAN/DESCRIPTION
1 2 3 4 5 6 7
1 KEADAAN BAN / TYRES CONDITION
1.1 BAN DEPAN / FRONT TYRES
1.2 BAN BELAKANG / REAR TYRES
1.3 BAN CADANGAN / SPARE TYRES
2 KACA / MIRROR / WINDSHIELD
2.1 KACA SPION (L/R) WING MIRROR
2.2 KACA SPION DALAM / REAR VIEW MIRROR
2.3 KACA DEPAN / WINDSHIELD
3 PERALATAN / TOOLS
3.1 DONGKRAK + HANDEL / JACK +HANDLE
3.2 KUNCI BAN / WHEEL WRENCH
4 LAMPU-LAMPU / LIGHTING SYSTEM
4.1 LAMPU KECIL / DIM LIGHT
4.2 LAMPU BESAR / HEAD LIGHT
4.3 LAMPU BELAKANG / TAIL LIGHT
4.4 LAMPU RUANGAN / INTERIOR LIGHT
4.5 LAMPU MUNDUR / REVERSING LIGHT
4.6 LAMPU REM / BREAKE LIGHT
4.7 LAMPU REATING / SIGNAL LIGHT
4.8 LAMPU TANDA DARURAT / EMERGENCY SIGNAL LIGHT
5 STNK / CAR REGISTER
6 PENANGKAPAN BARA / SPARK ARRESTOR
7 SABUK PENGAMAN / SEAT BELT
8 KOTAK OBAT / FIRST AID KIT
9 PEMADAM API RINGAN / HAND FIRE EXTINGUISHER
10 KLAKSON / HORN
11 KUNCI PINTU SISTEM / DOOR LOCKING SYSTEM
12 PENGHAPUS KACA / WIPERS
13 POMPA WIPER / WATER PUMP FOR CLEANING
WINDSHIELD
14 TEMPAT SAMPAH / GARBAGE PAIL
15 ACCU / BATTERY
16 / LUBRICATION SYSTEM
 16.1 OLI MESIN / LUBE OIL LEVEL
16.2 MINYAK REM / BRAKE FLUID
16.3 MINYAK KOPLING / CLUTCH FLUID
16.4 OLI POWER STERING / POWER STERING OIL LEVEL
16.5 TANKI RADIATOR / COOLING WATER RESERVE TANK
17 SISTEM BAHAN BAKAR / FUEL SYSTEM
JENIS KENDARAAN / VEHICLE TYPE :

17.1 LEVEL BAHAN BAKAR / FUEL TANK LEVEL

NO. PLAT / POLICE REGISTER NO :

17.2 PANAS MESIN / ENGINE TEMPERATURE

18 AC / AIR CONDITIONER
19 DOBEL GARDAN / 4WD SYSTEM
20 SYSTEM PENGEREMAN / BRAKE SYSTEM
20.1 REM TANGAN / HAND BRAKE
20.2 REM KAKI / MAIN BRAKE SYSTEM
21 LAIN-LAIN / OTHER
BULAN : Dilaporkan oleh,
 Nomor Formulir GKJ-FR-HSE-022

RAAN HARIAN Tanggal terbit

Tanggal efektif
Revisi
01 Juni 2016
01 Juli 2016
01

TANGGAL
8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30
Ditindak Lanjuti oleh,
GKJ-FR-HSE-022
01 Juni 2016
01 Juli 2016
01

31
anjuti oleh,