Lokasi / Tempat Pemeriksaan : ……………........................

Tanggal Pemeriksaan : ……………………................

I . DATA FORKLIFT :
DATA UMUM

Nama Equipment Tipe / Kapitas Maks

Pemilik Equipment Brand / Manufacturer
No. Item Dimension (Fork)
Tahun Pembuatan Forklift Class
Tahun Perakitan.
DOKUMEN

NAMA DOKUMEN ADA TIDAK KETERANGAN

ADA

BPKB
STNK
Sertifikat Forklift (Migas)

Sertifikat Operator
(Migas)
Manual Book
Operasional
Laporan inspeksi
sebelumnya
ENGINE

Brand / Manufacturer Jumlah Silinder

Model No. Voltage / Current

Serial No Freq./Phase
II. PEMERIKSAAN FORKLIFT
KETERANGAN
 NO. PERALATAN
1. LOAD LIFTING MECHANISM
1.1. Mast
Kepala Tiang (Upright)
Batang Utama (Mast)
Rangka Penguat (Stiffener)
Sambungan (Splices)
1.2. Carrier
Batang Utama (main Frame)
Rangka Penguat (Stiffener)
Rantai (Chain)
Sproket (Sprocket)
Engsel, Pin (Hinge / Pin)
1.3. Lift Cylinder
Lengan Mendatar (Horizontal
arm)
Selongsong Lengan (Arm
Box)
Pendongkrak Hidrolik (Hyd.
Jack)
Alas (Shoe / Pad)
1.4. Counterweght
Beban (Counter Weight)
Penyangga (Support)
Pengikatan (Bolting)
1.5. Fork
Garpu (Fork)
Sambungan Pengikat
(Bracket)
Sambungan Las (Welding)
Pengunci (Lock)
2. TRAVELLING MECANISM
Chasis (Chassis / Car Body)
Roda Depan (Front Wheel)
Roda Pengikut / tengah (Non
Drive Wheel)
Roda Belakang (Drive Wheel)
Gardan (Differential)
Sambungan Pengikat, baut
(bracket , Bolt)
Rem (travelling Brake)
3. PRIME MOVER
3.1. Engine
Rumah Mesin (Engine
Housing)
Badan Mesin (engine Block)
INSPEKSI CHECK FISIK KONDISI
ADA TIDAK BAIK TIDAK
ADA BAIK
Korosi, retak, bengkok
Korosi, retak, bengkok
Korosi, retak, bengkok
Aus, retak, bengkok
Korosi, retak, bengkok
Korosi, retak, bengkok
Longgar, retak, bengkok
Longgar, aus, bengkok
Longgar, retak, bengkok
Korosi, retak, bengkok
Korosi, retak, bengkok
Aus, bengkok, adjust
Aus, bengkok, adjust
Tersedia
Korosi, retak, bengkok
Aus, longgar
Korosi, retak, bengkok
Korosi, retak, bengkok
Korosi, retak, bengkok
Longgar, retak, bengkok
Korosi, retak, bengkok
Aus, tekanan, adjust
Aus, tekanan, adjust
Aus, tekanan, adjust
Korosi, retak, bengkok
Longgar, retak, bengkok
Aus, adjust
Korosi, bengkok, layak
Kotor, bocor, bengkok
 Dudukkan Mesin (Engine
Mounting)
Pembautan (Bolting)
3.2. Cooling / Lubrication
Radiator (Radiator)
Pelindung (Safety Guard)
Kipas & Tali (Fan & Belt)
Selang Air (Water Hose)
Tutup Pengisi (Cap)
Pelumasan (Lubrication)
3.3. Fuel System
Bahan Bakar (Fuel)
Tangki B. Bakar (Fuel Tank)
Pompa B. Bakar (Fuel Pump)
Saluran B. Bakar (Fuel Line)
Pembersih udara (Air Cleaner)
Manifold
Knalpot, anti api (Muffler,
Spark Arrestor)
4. ELECTRICAL SYSTEM
1 Sistem Kabel Kabin (Cabin
Wiring System)
Sistem Kabel Lampu (Lighting
System)
Sistem Kabel Aki (Battery
Wiring System)
Sistem Kabel Mesin (Engine
Wiring System)
Saklar / Kontraktor (Switch /
Contactor)
Sistem Pengaman (Main
Breaker)
Sistem Pembumian
(Grounding System)
Baterai (Battery)
Stater Listrik (Motor Stater)
5. HYDRAULIC SYSTEM
Pompa (Hydraulic Pump)
Pengumpul (Hydraulic
Accumulator)
Katub kendali (Control Valve)
Katub pembagi (Three Way
Valve)
Swievel Pusat (center Valve
Saluran Hidrolik
- Mengangkat
- Membalik
Layak, aus, longgar
Korosi, longgar
Level, Kontaminasi
Fit, bengkok, safety
Tension, aus, safety
Kontaminasi, safety
Fit, kebocoran
Level, kontaminasi
Kontaminasi
Penyok, bocor
Kotor, bocor, aus
Buntu, bocor, aus
Buntu, bocor, aus
Bocor, aus, safety
Bocor, aus, safety
Buruk, function
Buruk, function
Buruk, function
Buruk, function
Buruk, function
Buruk, function
Buruk, function
Level, sambungan,
ujung hub
Layak, sambungan, function
Kebocoran, function
Kontaminasi, kebocoran
Bocor, Function
Bocor, Function
Bocor, Function
Gompal, aus, bocor
Gompal, aus, bocor
 Katub - katub
- Mengangkat Gompal, aus, bocor
- Membalik Gompal, aus, bocor
Silinder Hidrolik
- Mengangkat Gompal, aus, bocor
- Membalik Gompal, aus, bocor
6. AIR / PNEUMATIC SYSTEM
1 Kompressor (Compessor Unit) Kontaminasi, bocor
Saluran Udara (Air line) Koyak, aus, bocor
Fiting (Fitting) Bengkok, aus, bocor
Katup Kendali (Control Valve) Bengkok, bocor
Tangki Penimbun (Air Kontaminasi, bocor
Receiver Tank)
Katup Pengaman (Pressure Adjust, fuction
Safety Valve)
Tangki Udara (Accumulator) Bocor, safety
Pompa (Charging Pump) Function
7. DRIVING CABIN
7.1. Structure
Rangka Dinding (Cabin Wall Korosi, retak, penyok
Frame)
Kursi, penguat (Seat, Bracket) Korosi, retak, koyak,
layak
Lantai (Platform, Floor) Korosi, retak, koyak,
layak
Tangga (Ladder) Korosi, retak, koyak,
layak
7.2. Control Unit
Kemudi (Wheel) Function, Layak
Tuas, Pedal, Kenop (joystik, Function, Layak
pedal, Push Button)
- Memutar (Slewing) Function, Layak
- Gas (Throtle) Function, Layak
- Rem (Brake) Function, Layak
- Rem parkir (Parking brake) Function, Layak
- Pasneling (Transmission) Function, Layak
- Kopling (Coupling) Function, Layak
KETERANGAN
 NO. PERALATAN INSPEKSI CHECK FISIK KONDISI

ADA TIDAK BAIK TIDAK

ADA BAIK
Tek. Pelumas (lubrication Function
gauge)
Tek. Udara (Air Pressure Function
Gauge)
Amper, Tegangan (Ampere, Function
Volt Meter)
Suhu Mesin (Engine Function
Temperature gauge)
Putaran Mesin (Tachometer) Function

Kecepatan Jalan Function

(Speedometer)
Tek. Hidrolik (Hydraulic Function
Pressure Gauge)
SAFETY DEVICE

Indikator Level (Level Gauge) Function

Indikator Sudut (Angle Function

Indicator)
Tek. Hidrolik (Hydraulic Function
Pressure Gauge)
Tabel Beban (Laod Chart) Tersedia

Penunjuk Beban (Load Function, akurat

Indicator)
Kunci Darurat (Emergency Function
Shutdown)
APAR (Portable Fire Kedaluarsa, Inspeksi
Extinguisher)

V. REKOMENDASI :
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VI. KESIMPULAN HASIL PEMERIKSAAN

Dari hasil Pemeriksaan disimpulkan, bahwa sebagai berikut : *)
 KETERANGAN

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1. Forklift LAIK Operasi.
2. Forklift LAIK Operasi dengan ketentuan dilakukan perbaikan sesuai butir V di atas.
3. Forklift TIDAK LAIK Operasi.

*) : Coret yang tidak perlu (X).

Dibuat oleh,
1. ..............................
Nama & Jabatan
2. .............................
Nama & Jabatan
n dilakukan perbaikan sesuai butir V di atas.

Disetujui oleh,
...........................
Nama & Jabatan