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SCAFFOLDING INSPECTION CHECK LIST

LOCATION :
SCAFFOLDING TYPE : GENERAL SCAFFOLD :
MAX LOAD :
CONSTRUCTED : DATE :

NO ITEM TO BE INSPECTION OK NOK REMARK


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 : INSPECTION BY :

Company Safety Dept. Superitendent 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

___________ ___________ ____________ ______________


INSPECTION FIRE EQUIPMENT FOR PREVENTIVE

Size Inspection
No Location Type Kg/Lt Date Service Expired Weekly Monthly Remark

A Tool Room 1. CO2 6,8 Kg. 10/1/2001 10/1/2002 4/8/2002


2. DC 6 Kg. 10/1/2001 10/1/2002 4/8/2002
3. DC 6 Kg. 10/1/2001 10/1/2002 4/8/2002
4. 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 4/8/2002


2. DC 6 Kg 10/1/2001 10/1/2002 4/8/2002
3. 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 4/8/2002


2. DC 6 Kg 10/1/2001 10/1/2002 4/8/2002
3. 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 4/8/2002


2. CO2 6,8 Kg 10/1/2001 10/1/2002 4/8/2002 Hose must be replace
3. CO2 6,8 Kg 10/1/2001 10/1/2002 4/8/2002
4. DC 6 Kg 10/1/2001 10/1/2002 4/8/2002
5. DC 40 Kg 10/1/2001 10/1/2002 4/8/2002
6. 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 Inspection
No 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.

c:\excel\form Inspection List