INDONESIA MOROWALI INDUSTRIAL PARK

SAFETY DEPARTEMENT

INSPEKSI KENDARAAN

Tanggal Inspeksi :............................................ Lokasi : ............................................

DATA KENDARAAN DATA PENGEMUDI

Merk/Manufacture : ............................................ Nama : ............................................

Tahun : ............................................ Jenis : ............................................

Jenis : ............................................ Umur : ............................................

Kapasitas : ............................................ Type SIM/No :................................

No Polisi : ............................................ Masa Berlaku SIM :............................

Masa KIR : ............................................ Pemakai : ..........................................

Pemilik Kendaraan : ............................................

NO ITEM STATUS KONDISI KETERANGAN

Ada Tidak Baik Buruk
ada
1 Surat-Surat Asli Kendaraan
2 Body & Chasis
3 Air Radiator
4 Minyak Rem
5 Oli Mesin
6 Beterai
7 System Rem
 Rem Tangan
 Rem Kaki
8 Mesin
9 Sistem Kemudi
10 Panel-panel Indikator
11 Air Pencuci Kaca
12 Klakson
13 Sabuk Pengaman (Sesuai
kapasitas duduk)
14 Pintu dan jendela
15 Kaca Spion
16  Kaca Spion kanan & kiri
 Kaca Spion dalam
17 Kaca depan
18 Kaca samping
 19 Pembersih kaca (Wiper)
20 Lampu Utama
21 Lampu Sein Kanan dan kiri
22 Lampu rem kanan dan kiri
23 Lampu Mundur
24 Alarm mundur
25 Kondisi roda
 Kiri depan
 Kanan depan
 Kiri belakang
 Kanan Belakang
26 Peralatan cadangan
 Roda cadangan
 Donkrak
 Kunci Roda
 Kunci Perlengakapan
27 Segitiga Pengaman
28 Kotak P3K
29 APAR
30 Lampu Rotary
31 Kait / Hook untuk Sing / Tali
32 Lain-lain :

CATATAN :

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Diinspeksi Oleh
Safety IMIP I-TRACC Department