INSPEKSI HYDRANT SETIAP 30 HARI Paraf

K3RS
BULAN: JAN FEB MAR APR MEI JUN JUL AGS SEP OKT NOV DES
KONDISI
No Ceklist Item Lokasi Hydrant Lantai Gedung
Baik Rusak
1 Control valve √
2 Pressure Gauge √
3 Perpipaan √
Klinik orthopedi
4 Sambungan selang √
5 Kondisi kabinet √
6 Isi kabinet Hydrant √
2
1 Control valve √
2 Pressure Gauge √
3 Perpipaan √
Depan pendaftaran BPJS
4 Sambungan selang √
5 Kondisi kabinet √
6 Isi kabinet Hydrant √
1
1 Control valve √
2 Pressure Gauge √
3 Perpipaan √
Depan toilet belakang IGD lama
4 Sambungan selang √
5 Kondisi kabinet √
6 Isi kabinet Hydrant √
1
1 Control valve √
2 Pressure Gauge √
3 Perpipaan IGD lama (Kondisi terhalang baby √
4 Sambungan selang incubator) √
5 Kondisi kabinet √
6 Isi kabinet Hydrant √
 0

INSPEKSI HYDRANT SETIAP 30 HARI Paraf

K3RS
BULAN: JAN FEB MAR APR MEI JUN JUL AGS SEP OKT NOV DES
KONDISI
No Ceklist Item Lokasi Hydrant Lantai Gedung
Baik Rusak
1 Control valve √
2 Pressure Gauge √
3 Perpipaan √
Depan poliklinik rehab medik 1
4 Sambungan selang √
5 Kondisi kabinet √
6 Isi kabinet Hydrant √

1 Control valve √
2 Pressure Gauge √
3 Perpipaan √
Aula komite medik 5 2
4 Sambungan selang √
5 Kondisi kabinet √
6 Isi kabinet Hydrant √

1 Control valve √
2 Pressure Gauge √
3 Perpipaan √
Rekam medik 2
4 Sambungan selang √
5 Kondisi kabinet √
6 Isi kabinet Hydrant √

INSPEKSI HYDRANT SETIAP 30 HARI Paraf

K3RS
 K3RS
BULAN: JAN FEB MAR APR MEI JUN JUL AGS SEP OKT NOV DES
KONDISI
No Ceklist Item Lokasi Hydrant Lantai Gedung
Baik Rusak
1 Control valve √
2 Pressure Gauge √
3 Perpipaan √
Wing covid
4 Sambungan selang √
5 Kondisi kabinet √
6 Isi kabinet Hydrant √
1
1 Control valve √
2 Pressure Gauge √
3 Perpipaan √
Belakang wing covid
4 Sambungan selang √
5 Kondisi kabinet √
6 Isi kabinet Hydrant √
4
1 Control valve √
2 Pressure Gauge √
3 Perpipaan √
Poli B20
4 Sambungan selang √
5 Kondisi kabinet √
6 Isi kabinet Hydrant √
2
1 Control valve √
2 Pressure Gauge √
3 Perpipaan √
Ruang RO
4 Sambungan selang √
5 Kondisi kabinet √
6 Isi kabinet Hydrant √

INSPEKSI HYDRANT SETIAP 30 HARI Paraf

K3RS
BULAN: JAN FEB MAR APR MEI JUN JUL AGS SEP OKT NOV DES
KONDISI
No Ceklist Item Lokasi Hydrant Lantai Gedung
Baik Rusak
1 Control valve √
2 Pressure Gauge √
3 Perpipaan √
IGD Baru
4 Sambungan selang √
5 Kondisi kabinet √
6 Isi kabinet Hydrant √

1 Control valve √
2 Pressure Gauge √
3 Perpipaan √
R. Radiologi 1
4 Sambungan selang √
5 Kondisi kabinet √
6 Isi kabinet Hydrant √

1 Control valve √
2 Pressure Gauge √
3 Perpipaan √
Laboratorium
4 Sambungan selang √
5 Kondisi kabinet √
6 Isi kabinet Hydrant √

1 Control valve √
2 Pressure Gauge √
3 Perpipaan √
PICU 2
4 Sambungan selang √
5 Kondisi kabinet √
6 Isi kabinet Hydrant √

1 Control valve √
2 Pressure Gauge √
3 Perpipaan √
Dalam R. OK
4 Sambungan selang √
5 Kondisi kabinet √
6 Isi kabinet Hydrant √
3
1 Control valve √
2 Pressure Gauge √
3 Perpipaan √
Dalam R. CSSD
4 Sambungan selang √
5 Kondisi kabinet √
6 Isi kabinet Hydrant √

1 Control valve √
2 Pressure Gauge √
3 Perpipaan √
R. Aula Rapat
4 Sambungan selang √
5 Kondisi kabinet √
6 Isi kabinet Hydrant √
4
1 Control valve √
2 Pressure Gauge √
3 Perpipaan √
R. Management
4 Sambungan selang √
5 Kondisi kabinet √
6 Isi kabinet Hydrant √
3
1 Control valve √
2 Pressure Gauge √
3 Perpipaan √
Nurse Station
4 Sambungan selang √
5 Kondisi kabinet √
6 Isi kabinet Hydrant √
5
1 Control valve √
2 Pressure Gauge √
3 Perpipaan √
Nurse Station
4 Sambungan selang √
5 Kondisi kabinet √
6 Isi kabinet Hydrant √

1 Control valve √
2 Pressure Gauge √
3 Perpipaan √
Nurse Station
4 Sambungan selang √
5 Kondisi kabinet √
6 Isi kabinet Hydrant √
6
1 Control valve √
2 Pressure Gauge √
3 Perpipaan √
Nurse Station
4 Sambungan selang √
5 Kondisi kabinet √
6 Isi kabinet Hydrant √

1 Control valve √
2 Pressure Gauge √
3 Perpipaan √
Nurse Station (R. Rawat VIP)
4 Sambungan selang √
5 Kondisi kabinet √
6 Isi kabinet Hydrant √
7
1 Control valve √
2 Pressure Gauge √
3 Perpipaan √
Nurse Station (R. Rawat VIP)
4 Sambungan selang √
5 Kondisi kabinet √
6 Isi kabinet Hydrant √

1 Control valve √
2 Pressure Gauge √
3 Perpipaan √
4 Sambungan selang √
5 Kondisi kabinet √
6 Isi kabinet Hydrant √
Aula Besar 8
1 Control valve √
2 Pressure Gauge √
3 Perpipaan √
4 Sambungan selang √
5 Kondisi kabinet √
6 Isi kabinet Hydrant √
 INSPEKSI HYDRANT SETIAP 30 HARI Paraf
K3RS
BULAN: JAN FEB MAR APR MEI JUN JUL AGS SEP OKT NOV DES
KONDISI
No Ceklist Item Lokasi Hydrant Lantai Gedung
Baik Rusak
1 Control valve √
2 Pressure Gauge √
3 Perpipaan √
Isolasi paru
4 Sambungan selang √
5 Kondisi kabinet √
6 Isi kabinet Hydrant √
1
1 Control valve √
2 Pressure Gauge √
3 Perpipaan √
Belakang isolasi paru
4 Sambungan selang √
5 Kondisi kabinet √
6 Isi kabinet Hydrant √
3
1 Control valve √
2 Pressure Gauge √
3 Perpipaan √
Klinik anak
4 Sambungan selang √
5 Kondisi kabinet √
6 Isi kabinet Hydrant √
2
1 Control valve √
2 Pressure Gauge √
3 Perpipaan √
Connecting bedah umum
4 Sambungan selang √
5 Kondisi kabinet √
6 Isi kabinet Hydrant √
 INSPEKSI HYDRANT SETIAP 30 HARI Paraf
K3RS
BULAN: JAN FEB MAR APR MEI JUN JUL AGS SEP OKT NOV DES
KONDISI
No Ceklist Item Lokasi Hydrant Lantai Gedung
Baik Rusak
1 Control valve √
2 Pressure Gauge √
3 Perpipaan √
Poli DM
4 Sambungan selang √
5 Kondisi kabinet √
6 Isi kabinet Hydrant √
2
1 Control valve √
2 Pressure Gauge √
3 Perpipaan √
Depan VK 3 2
4 Sambungan selang √
5 Kondisi kabinet √
6 Isi kabinet Hydrant √

1 Control valve √
2 Pressure Gauge √
3 Perpipaan √
ICU covid 1
4 Sambungan selang √
5 Kondisi kabinet √
6 Isi kabinet Hydrant √

INSPEKSI HYDRANT SETIAP 30 HARI Paraf

K3RS
 K3RS
BULAN: JAN FEB MAR APR MEI JUN JUL AGS SEP OKT NOV DES
KONDISI
No Ceklist Item Lokasi Hydrant Lantai Gedung
Baik Rusak
1 Control valve √
2 Pressure Gauge √
3 Perpipaan √
Lobby
4 Sambungan selang √
5 Kondisi kabinet √
6 Isi kabinet Hydrant √

1 Control valve √
2 Pressure Gauge √
3 Perpipaan √
Depan UGD (Lama)
4 Sambungan selang √
5 Kondisi kabinet √
6 Isi kabinet Hydrant √

1 Control valve √
2 Pressure Gauge √
3 Perpipaan √
Samping WTP
4 Sambungan selang √
5 Kondisi kabinet √
6 Isi kabinet Hydrant √

1 Control valve √
2 Pressure Gauge √
3 Perpipaan Luar √
Depan Masjid 1
4 Sambungan selang Gedung √
5 Kondisi kabinet √
6 Isi kabinet Hydrant √

1 Control valve √
2 Pressure Gauge √
3 Perpipaan √
4 Sambungan selang √
5 Kondisi kabinet √
6 Isi kabinet Hydrant √
 1 Control valve √
2 Pressure Gauge √
3 Perpipaan √
Parkir Mobil
4 Sambungan selang √
5 Kondisi kabinet √
6 Isi kabinet Hydrant √

1 Control valve √
2 Pressure Gauge √
3 Perpipaan √
4 Sambungan selang √
5 Kondisi kabinet √
6 Isi kabinet Hydrant √

INSPEKSI HYDRANT SETIAP 30 HARI Paraf

K3RS
BULAN: JAN FEB MAR APR MEI JUN JUL AGS SEP OKT NOV DES
KONDISI
No Ceklist Item Lokasi Hydrant Lantai Gedung
Baik Rusak
1 Control valve √
2 Pressure Gauge √
3 Perpipaan √
4 Sambungan selang √
5 Kondisi kabinet √
6 Isi kabinet Hydrant √

1 Control valve √
2 Pressure Gauge √
3 Perpipaan √
4 Sambungan selang √
5 Kondisi kabinet √
6 Isi kabinet Hydrant √

1 Control valve √
2 Pressure Gauge √
 3 Perpipaan √
4 Sambungan selang √
5 Kondisi kabinet √
6 Isi kabinet Hydrant √
Luar
Parkir Gedung 3&4 1
Gedung
1 Control valve √
2 Pressure Gauge √
3 Perpipaan √
4 Sambungan selang √
5 Kondisi kabinet √
6 Isi kabinet Hydrant √

1 Control valve √
2 Pressure Gauge √
3 Perpipaan √
4 Sambungan selang √
5 Kondisi kabinet √
6 Isi kabinet Hydrant √

1 Control valve √
2 Pressure Gauge √
3 Perpipaan √
4 Sambungan selang √
5 Kondisi kabinet √
6 Isi kabinet Hydrant √

INSPEKSI HYDRANT SETIAP 30 HARI Paraf

K3RS
BULAN: JAN FEB MAR APR MEI JUN JUL AGS SEP OKT NOV DES
KONDISI
No Ceklist Item Lokasi Hydrant Lantai Gedung
Baik Rusak
1 Control valve √
2 Pressure Gauge √
3 Perpipaan √
Selasar Linen 1
4 Sambungan selang √
5 Kondisi kabinet √
6 Isi kabinet Hydrant √

1 Control valve √
2 Pressure Gauge √
3 Perpipaan √
Depan R. Control 2
4 Sambungan selang √
5 Kondisi kabinet √
6 Isi kabinet Hydrant √
4 (Linen)
1 Control valve √
2 Pressure Gauge √
3 Perpipaan √
R. Farmasi 3
4 Sambungan selang √
5 Kondisi kabinet √
6 Isi kabinet Hydrant √

1 Control valve √
2 Pressure Gauge √
3 Perpipaan √
Depan Gudang Galon Gizi 4
4 Sambungan selang √
5 Kondisi kabinet √
6 Isi kabinet Hydrant √
 INSPEKSI HYDRANT SETIAP 30 HARI

BULAN: JAN FEB MAR APR MEI JUN JUL AGS

No Ceklist Item Lokasi Hydrant

1 Control valve
2 Pressure Gauge
3 Perpipaan
Klinik orthopedi
4 Sambungan selang
5 Kondisi kabinet
6 Isi kabinet Hydrant

1 Control valve
2 Pressure Gauge
3 Perpipaan
Depan pendaftaran BPJS
4 Sambungan selang
5 Kondisi kabinet
6 Isi kabinet Hydrant

1 Control valve
2 Pressure Gauge
3 Perpipaan
Depan toilet belakang IGD lama
4 Sambungan selang
5 Kondisi kabinet
6 Isi kabinet Hydrant

1 Control valve
2 Pressure Gauge
3 Perpipaan IGD lama (Kondisi terhalang baby
4 Sambungan selang incubator)
5 Kondisi kabinet
6 Isi kabinet Hydrant

INSPEKSI HYDRANT SETIAP 30 HARI

BULAN: JAN FEB MAR APR MEI JUN JUL AGS

No Ceklist Item Lokasi Hydrant

 1 Control valve
2 Pressure Gauge
3 Perpipaan
Depan poliklinik rehab medik
4 Sambungan selang
5 Kondisi kabinet
6 Isi kabinet Hydrant

1 Control valve
2 Pressure Gauge
3 Perpipaan
Aula komite medik
4 Sambungan selang
5 Kondisi kabinet
6 Isi kabinet Hydrant

1 Control valve
2 Pressure Gauge
3 Perpipaan
Rekam medik
4 Sambungan selang
5 Kondisi kabinet
6 Isi kabinet Hydrant

INSPEKSI HYDRANT SETIAP 30 HARI

BULAN: JAN FEB MAR APR MEI JUN JUL AGS

No Ceklist Item Lokasi Hydrant

1 Control valve
2 Pressure Gauge
3 Perpipaan
Wing covid
4 Sambungan selang
5 Kondisi kabinet
6 Isi kabinet Hydrant

1 Control valve
2 Pressure Gauge

Belakang wing covid

 3 Perpipaan
Belakang wing covid
4 Sambungan selang
5 Kondisi kabinet
6 Isi kabinet Hydrant

1 Control valve
2 Pressure Gauge
3 Perpipaan
Poli B20
4 Sambungan selang
5 Kondisi kabinet
6 Isi kabinet Hydrant

1 Control valve
2 Pressure Gauge
3 Perpipaan
Ruang RO
4 Sambungan selang
5 Kondisi kabinet
6 Isi kabinet Hydrant

INSPEKSI HYDRANT SETIAP 30 HARI

BULAN: JAN FEB MAR APR MEI JUN JUL AGS

No Ceklist Item Lokasi Hydrant

1 Control valve
2 Pressure Gauge
3 Perpipaan
IGD Baru
4 Sambungan selang
5 Kondisi kabinet
6 Isi kabinet Hydrant

1 Control valve
2 Pressure Gauge
3 Perpipaan
R. Radiologi
4 Sambungan selang
5 Kondisi kabinet
6 Isi kabinet Hydrant

1 Control valve
2 Pressure Gauge
3 Perpipaan
Laboratorium
4 Sambungan selang
 Laboratorium

5 Kondisi kabinet
6 Isi kabinet Hydrant

1 Control valve
2 Pressure Gauge
3 Perpipaan
PICU
4 Sambungan selang
5 Kondisi kabinet
6 Isi kabinet Hydrant

1 Control valve
2 Pressure Gauge
3 Perpipaan
Dalam R. OK
4 Sambungan selang
5 Kondisi kabinet
6 Isi kabinet Hydrant

1 Control valve
2 Pressure Gauge
3 Perpipaan
Dalam R. CSSD
4 Sambungan selang
5 Kondisi kabinet
6 Isi kabinet Hydrant

1 Control valve
2 Pressure Gauge
3 Perpipaan
R. Aula Rapat
4 Sambungan selang
5 Kondisi kabinet
6 Isi kabinet Hydrant

1 Control valve
2 Pressure Gauge
3 Perpipaan
R. Management
4 Sambungan selang
5 Kondisi kabinet
6 Isi kabinet Hydrant

1 Control valve
2 Pressure Gauge
3 Perpipaan
Nurse Station
4 Sambungan selang
5 Kondisi kabinet
 Nurse Station

6 Isi kabinet Hydrant

1 Control valve
2 Pressure Gauge
3 Perpipaan
Nurse Station
4 Sambungan selang
5 Kondisi kabinet
6 Isi kabinet Hydrant

1 Control valve
2 Pressure Gauge
3 Perpipaan
Nurse Station
4 Sambungan selang
5 Kondisi kabinet
6 Isi kabinet Hydrant

1 Control valve
2 Pressure Gauge
3 Perpipaan
Nurse Station
4 Sambungan selang
5 Kondisi kabinet
6 Isi kabinet Hydrant

1 Control valve
2 Pressure Gauge
3 Perpipaan
Nurse Station (R. Rawat VIP)
4 Sambungan selang
5 Kondisi kabinet
6 Isi kabinet Hydrant

1 Control valve
2 Pressure Gauge
3 Perpipaan
Nurse Station (R. Rawat VIP)
4 Sambungan selang
5 Kondisi kabinet
6 Isi kabinet Hydrant

1 Control valve
2 Pressure Gauge
3 Perpipaan
4 Sambungan selang
5 Kondisi kabinet
6 Isi kabinet Hydrant
Aula Besar
 Aula Besar
1 Control valve
2 Pressure Gauge
3 Perpipaan
4 Sambungan selang
5 Kondisi kabinet
6 Isi kabinet Hydrant
ARI Paraf
K3RS
SEP OKT NOV DES BULAN: JAN FEB
KONDISI
Lantai Gedung No Ceklist Item
Baik Rusak
√ 1 Control valve
√ 2 Pressure Gauge
√ 3 Perpipaan
√ 4 Sambungan selang
√ 5 Kondisi kabinet
√ 6 Isi kabinet Hydrant
2
√ 1 Control valve
√ 2 Pressure Gauge
√ 3 Perpipaan
√ 4 Sambungan selang
√ 5 Kondisi kabinet
√ 6 Isi kabinet Hydrant
1
√ 1 Control valve
√ 2 Pressure Gauge
√ 3 Perpipaan
√ 4 Sambungan selang
√ 5 Kondisi kabinet
√ 6 Isi kabinet Hydrant
1
√ 1 Control valve
√ 2 Pressure Gauge
√ 3 Perpipaan
√ 4 Sambungan selang
√ 5 Kondisi kabinet
√ 6 Isi kabinet Hydrant

ARI Paraf
K3RS
SEP OKT NOV DES BULAN: JAN FEB
KONDISI
Lantai Gedung No Ceklist Item
Baik Rusak
 √ 1 Control valve
√ 2 Pressure Gauge
√ 3 Perpipaan
1
√ 4 Sambungan selang
√ 5 Kondisi kabinet
√ 6 Isi kabinet Hydrant

√ 1 Control valve
√ 2 Pressure Gauge
√ 3 Perpipaan
5 2
√ 4 Sambungan selang
√ 5 Kondisi kabinet
√ 6 Isi kabinet Hydrant

√ 1 Control valve
√ 2 Pressure Gauge
√ 3 Perpipaan
2
√ 4 Sambungan selang
√ 5 Kondisi kabinet
√ 6 Isi kabinet Hydrant

ARI Paraf
K3RS
SEP OKT NOV DES BULAN: JAN FEB
KONDISI
Lantai Gedung No Ceklist Item
Baik Rusak
√ 1 Control valve
√ 2 Pressure Gauge
√ 3 Perpipaan
√ 4 Sambungan selang
√ 5 Kondisi kabinet
√ 6 Isi kabinet Hydrant
1
√ 1 Control valve
√ 2 Pressure Gauge
 1

√ 3 Perpipaan
√ 4 Sambungan selang
√ 5 Kondisi kabinet
√ 6 Isi kabinet Hydrant
4
√ 1 Control valve
√ 2 Pressure Gauge
√ 3 Perpipaan
√ 4 Sambungan selang
√ 5 Kondisi kabinet
√ 6 Isi kabinet Hydrant
2
√ 1 Control valve
√ 2 Pressure Gauge
√ 3 Perpipaan
√ 4 Sambungan selang
√ 5 Kondisi kabinet
√ 6 Isi kabinet Hydrant

1 Control valve
2 Pressure Gauge
ARI Paraf
K3RS 3 Perpipaan
SEP OKT NOV DES 4 Sambungan selang
KONDISI 5 Kondisi kabinet
Lantai Gedung
Baik Rusak 6 Isi kabinet Hydrant
√
√ 1 Control valve
√ 2 Pressure Gauge
√ 3 Perpipaan
√ 4 Sambungan selang
√ 5 Kondisi kabinet
6 Isi kabinet Hydrant
√
√ 1 Control valve
√ 2 Pressure Gauge
1
√ 3 Perpipaan
√ 4 Sambungan selang
√ 5 Kondisi kabinet
6 Isi kabinet Hydrant
√
√
√
√
 √ BULAN: JAN FEB
√
No Ceklist Item

√ 1 Control valve
√ 2 Pressure Gauge
√ 3 Perpipaan
2
√ 4 Sambungan selang
√ 5 Kondisi kabinet
√ 6 Isi kabinet Hydrant

√ 1 Control valve
√ 2 Pressure Gauge
√ 3 Perpipaan
√ 4 Sambungan selang
√ 5 Kondisi kabinet
√ 6 Isi kabinet Hydrant
3
√ 1 Control valve
√ 2 Pressure Gauge
√ 3 Perpipaan
√ 4 Sambungan selang
√ 5 Kondisi kabinet
√ 6 Isi kabinet Hydrant

√ 1 Control valve
√ 2 Pressure Gauge
√ 3 Perpipaan
√ 4 Sambungan selang
√ 5 Kondisi kabinet
√ 6 Isi kabinet Hydrant
4
√ 1 Control valve
√ 2 Pressure Gauge
√ 3 Perpipaan
√ 4 Sambungan selang
√ 5 Kondisi kabinet
√ 6 Isi kabinet Hydrant
3
√ 1 Control valve
√ 2 Pressure Gauge
√ 3 Perpipaan
√ 4 Sambungan selang
√ 5 Kondisi kabinet

5
 √ 6 Isi kabinet Hydrant
5
√
√
√
√ BULAN: JAN FEB
√
No Ceklist Item
√
1 Control valve
√ 2 Pressure Gauge
√ 3 Perpipaan
√ 4 Sambungan selang
√ 5 Kondisi kabinet
√ 6 Isi kabinet Hydrant
√
6 1 Control valve
√ 2 Pressure Gauge
√ 3 Perpipaan
√ 4 Sambungan selang
√ 5 Kondisi kabinet
√ 6 Isi kabinet Hydrant
√
1 Control valve
√ 2 Pressure Gauge
√ 3 Perpipaan
√ 4 Sambungan selang
√ 5 Kondisi kabinet
√ 6 Isi kabinet Hydrant
√
7 1 Control valve
√ 2 Pressure Gauge
√ 3 Perpipaan
√ 4 Sambungan selang
√ 5 Kondisi kabinet
√ 6 Isi kabinet Hydrant
√

√
√
√
√
√
√
8
8
√
√
√
√
√
√
 INSPEKSI HYDRANT SETIAP 30 HARI

MAR APR MEI JUN JUL AGS SEP OKT NOV DES

Ceklist Item Lokasi Hydrant Lantai Gedung

alve

n
Isolasi paru
an selang

1
alve
Gauge
n
Belakang isolasi paru
an selang
abinet
t Hydrant
3
alve
Gauge
n
Klinik anak
an selang
abinet
t Hydrant
2
alve
Gauge
n
Connecting bedah umum
an selang
abinet
t Hydrant

INSPEKSI HYDRANT SETIAP 30 HARI

MAR APR MEI JUN JUL AGS SEP OKT NOV DES

Ceklist Item Lokasi Hydrant Lantai Gedung

alve

n
Poli DM
an selang

2
alve
Gauge
n
Depan VK 3 2
an selang
abinet
t Hydrant

alve
Gauge
n
ICU covid 1
an selang
abinet
t Hydrant

INSPEKSI HYDRANT SETIAP 30 HARI

MAR APR MEI JUN JUL AGS SEP OKT NOV DES

Ceklist Item Lokasi Hydrant Lantai Gedung

alve

n
Lobby
an selang

alve
Gauge

Depan UGD (Lama)

n
Depan UGD (Lama)
an selang
abinet
t Hydrant

alve
Gauge
n
Samping WTP
an selang
abinet
t Hydrant

alve
Gauge
n Luar
Depan Masjid 1
an selang Gedung
abinet
t Hydrant

alve
Gauge
n
an selang
abinet
t Hydrant

alve
Gauge
n
Parkir Mobil
an selang
abinet
t Hydrant

alve
Gauge
n
an selang
abinet
t Hydrant

INSPEKSI HYDRANT SETIAP 30 HARI

 MAR APR MEI JUN JUL AGS SEP OKT NOV DES

Ceklist Item Lokasi Hydrant Lantai Gedung

alve

n
an selang

alve
Gauge
n
an selang
abinet
t Hydrant

alve
Gauge
n
an selang
abinet
t Hydrant
Luar
Parkir Gedung 3&4 1
Gedung
alve
Gauge
n
an selang
abinet
t Hydrant

alve
Gauge
n
an selang
abinet
t Hydrant

alve
Gauge
n
an selang
abinet
t Hydrant

INSPEKSI HYDRANT SETIAP 30 HARI

MAR APR MEI JUN JUL AGS SEP OKT NOV DES

Ceklist Item Lokasi Hydrant Lantai Gedung

alve

n
Selasar Linen 1
an selang

alve
Gauge
n
Depan R. Control 2
an selang
abinet
t Hydrant
4 (Linen)
alve
Gauge
n
R. Farmasi 3
an selang
abinet
t Hydrant

alve
Gauge
n
Depan Gudang Galon Gizi 4
an selang
abinet
t Hydrant
 Paraf
K3RS

KONDISI
Baik Rusak
√
√
√
√
√
√

√
√
√
√
√
√

√
√
√
√
√
√

√
√
√
√
√
√

Paraf
K3RS

KONDISI
Baik Rusak
√
√
√
√
√
√

√
√
√
√
√
√

√
√
√
√
√
√

Paraf
K3RS

KONDISI
Baik Rusak
√
√
√
√
√
√

√
√
√
√
√
√

√
√
√
√
√
√

√
√
√
√
√
√

√
√
√
√
√
√

√
√
√
√
√
√

√
√
√
√
√
√

Paraf
K3RS
 Paraf
K3RS

KONDISI
Baik Rusak
√
√
√
√
√
√

√
√
√
√
√
√

√
√
√
√
√
√

√
√
√
√
√
√

√
√
√
√
√
√

√
√
√
√
√
√

Paraf
K3RS

KONDISI
Baik Rusak
√
√
√
√
√
√

√
√
√
√
√
√

√
√
√
√
√
√

√
√
√
√
√
√
 INSPEKSI HYDRANT SETIAP 30 HARI

BULAN: JAN FEB MAR APR MEI JUN JUL AGS

No Ceklist Item Lokasi Hydrant

1 Control valve
2 Pressure Gauge
3 Perpipaan
Klinik orthopedi
4 Sambungan selang
5 Kondisi kabinet
6 Isi kabinet Hydrant

1 Control valve
2 Pressure Gauge
3 Perpipaan
Depan pendaftaran BPJS
4 Sambungan selang
5 Kondisi kabinet
6 Isi kabinet Hydrant

1 Control valve
2 Pressure Gauge
3 Perpipaan
Depan toilet belakang IGD lama
4 Sambungan selang
5 Kondisi kabinet
6 Isi kabinet Hydrant

1 Control valve
2 Pressure Gauge
3 Perpipaan IGD lama (Kondisi terhalang baby
4 Sambungan selang incubator)
5 Kondisi kabinet
6 Isi kabinet Hydrant

INSPEKSI HYDRANT SETIAP 30 HARI

BULAN: JAN FEB MAR APR MEI JUN JUL AGS

No Ceklist Item Lokasi Hydrant

 1 Control valve
2 Pressure Gauge
3 Perpipaan
Depan poliklinik rehab medik
4 Sambungan selang
5 Kondisi kabinet
6 Isi kabinet Hydrant

1 Control valve
2 Pressure Gauge
3 Perpipaan
Aula komite medik
4 Sambungan selang
5 Kondisi kabinet
6 Isi kabinet Hydrant

1 Control valve
2 Pressure Gauge
3 Perpipaan
Rekam medik
4 Sambungan selang
5 Kondisi kabinet
6 Isi kabinet Hydrant

INSPEKSI HYDRANT SETIAP 30 HARI

BULAN: JAN FEB MAR APR MEI JUN JUL AGS

No Ceklist Item Lokasi Hydrant

1 Control valve
2 Pressure Gauge
3 Perpipaan
Wing covid
4 Sambungan selang
5 Kondisi kabinet
6 Isi kabinet Hydrant

1 Control valve
2 Pressure Gauge

Belakang wing covid

 3 Perpipaan
Belakang wing covid
4 Sambungan selang
5 Kondisi kabinet
6 Isi kabinet Hydrant

1 Control valve
2 Pressure Gauge
3 Perpipaan
Poli B20
4 Sambungan selang
5 Kondisi kabinet
6 Isi kabinet Hydrant

1 Control valve
2 Pressure Gauge
3 Perpipaan
Ruang RO
4 Sambungan selang
5 Kondisi kabinet
6 Isi kabinet Hydrant

INSPEKSI HYDRANT SETIAP 30 HARI

BULAN: JAN FEB MAR APR MEI JUN JUL AGS

No Ceklist Item Lokasi Hydrant

1 Control valve
2 Pressure Gauge
3 Perpipaan
IGD Baru
4 Sambungan selang
5 Kondisi kabinet
6 Isi kabinet Hydrant

1 Control valve
2 Pressure Gauge
3 Perpipaan
R. Radiologi
4 Sambungan selang
5 Kondisi kabinet
6 Isi kabinet Hydrant

1 Control valve
2 Pressure Gauge
3 Perpipaan
Laboratorium
4 Sambungan selang
 Laboratorium

5 Kondisi kabinet
6 Isi kabinet Hydrant

1 Control valve
2 Pressure Gauge
3 Perpipaan
PICU
4 Sambungan selang
5 Kondisi kabinet
6 Isi kabinet Hydrant

1 Control valve
2 Pressure Gauge
3 Perpipaan
Dalam R. OK
4 Sambungan selang
5 Kondisi kabinet
6 Isi kabinet Hydrant

1 Control valve
2 Pressure Gauge
3 Perpipaan
Dalam R. CSSD
4 Sambungan selang
5 Kondisi kabinet
6 Isi kabinet Hydrant

1 Control valve
2 Pressure Gauge
3 Perpipaan
R. Aula Rapat
4 Sambungan selang
5 Kondisi kabinet
6 Isi kabinet Hydrant

1 Control valve
2 Pressure Gauge
3 Perpipaan
R. Management
4 Sambungan selang
5 Kondisi kabinet
6 Isi kabinet Hydrant

1 Control valve
2 Pressure Gauge
3 Perpipaan
Nurse Station
4 Sambungan selang
5 Kondisi kabinet
 Nurse Station

6 Isi kabinet Hydrant

1 Control valve
2 Pressure Gauge
3 Perpipaan
Nurse Station
4 Sambungan selang
5 Kondisi kabinet
6 Isi kabinet Hydrant

1 Control valve
2 Pressure Gauge
3 Perpipaan
Nurse Station
4 Sambungan selang
5 Kondisi kabinet
6 Isi kabinet Hydrant

1 Control valve
2 Pressure Gauge
3 Perpipaan
Nurse Station
4 Sambungan selang
5 Kondisi kabinet
6 Isi kabinet Hydrant

1 Control valve
2 Pressure Gauge
3 Perpipaan
Nurse Station (R. Rawat VIP)
4 Sambungan selang
5 Kondisi kabinet
6 Isi kabinet Hydrant

1 Control valve
2 Pressure Gauge
3 Perpipaan
Nurse Station (R. Rawat VIP)
4 Sambungan selang
5 Kondisi kabinet
6 Isi kabinet Hydrant

1 Control valve
2 Pressure Gauge
3 Perpipaan
4 Sambungan selang
5 Kondisi kabinet
6 Isi kabinet Hydrant
Aula Besar
 Aula Besar
1 Control valve
2 Pressure Gauge
3 Perpipaan
4 Sambungan selang
5 Kondisi kabinet
6 Isi kabinet Hydrant
ARI Paraf
K3RS
SEP OKT NOV DES BULAN: JAN FEB
KONDISI
Lantai Gedung No Ceklist Item
Baik Rusak
√ 1 Control valve
√ 2 Pressure Gauge
√ 3 Perpipaan
√ 4 Sambungan selang
√ 5 Kondisi kabinet
√ 6 Isi kabinet Hydrant
2
√ 1 Control valve
√ 2 Pressure Gauge
√ 3 Perpipaan
√ 4 Sambungan selang
√ 5 Kondisi kabinet
√ 6 Isi kabinet Hydrant
1
√ 1 Control valve
√ 2 Pressure Gauge
√ 3 Perpipaan
√ 4 Sambungan selang
√ 5 Kondisi kabinet
√ 6 Isi kabinet Hydrant
1
√ 1 Control valve
√ 2 Pressure Gauge
√ 3 Perpipaan
√ 4 Sambungan selang
√ 5 Kondisi kabinet
√ 6 Isi kabinet Hydrant

ARI Paraf
K3RS
SEP OKT NOV DES BULAN: JAN FEB
KONDISI
Lantai Gedung No Ceklist Item
Baik Rusak
 √ 1 Control valve
√ 2 Pressure Gauge
√ 3 Perpipaan
1
√ 4 Sambungan selang
√ 5 Kondisi kabinet
√ 6 Isi kabinet Hydrant

√ 1 Control valve
√ 2 Pressure Gauge
√ 3 Perpipaan
5 2
√ 4 Sambungan selang
√ 5 Kondisi kabinet
√ 6 Isi kabinet Hydrant

√ 1 Control valve
√ 2 Pressure Gauge
√ 3 Perpipaan
2
√ 4 Sambungan selang
√ 5 Kondisi kabinet
√ 6 Isi kabinet Hydrant

ARI Paraf
K3RS
SEP OKT NOV DES BULAN: JAN FEB
KONDISI
Lantai Gedung No Ceklist Item
Baik Rusak
√ 1 Control valve
√ 2 Pressure Gauge
√ 3 Perpipaan
√ 4 Sambungan selang
√ 5 Kondisi kabinet
√ 6 Isi kabinet Hydrant
1
√ 1 Control valve
√ 2 Pressure Gauge
 1

√ 3 Perpipaan
√ 4 Sambungan selang
√ 5 Kondisi kabinet
√ 6 Isi kabinet Hydrant
4
√ 1 Control valve
√ 2 Pressure Gauge
√ 3 Perpipaan
√ 4 Sambungan selang
√ 5 Kondisi kabinet
√ 6 Isi kabinet Hydrant
2
√ 1 Control valve
√ 2 Pressure Gauge
√ 3 Perpipaan
√ 4 Sambungan selang
√ 5 Kondisi kabinet
√ 6 Isi kabinet Hydrant

1 Control valve
2 Pressure Gauge
ARI Paraf
K3RS 3 Perpipaan
SEP OKT NOV DES 4 Sambungan selang
KONDISI 5 Kondisi kabinet
Lantai Gedung
Baik Rusak 6 Isi kabinet Hydrant
√
√ 1 Control valve
√ 2 Pressure Gauge
√ 3 Perpipaan
√ 4 Sambungan selang
√ 5 Kondisi kabinet
6 Isi kabinet Hydrant
√
√ 1 Control valve
√ 2 Pressure Gauge
1
√ 3 Perpipaan
√ 4 Sambungan selang
√ 5 Kondisi kabinet
6 Isi kabinet Hydrant
√
√
√
√
 √ BULAN: JAN FEB
√
No Ceklist Item

√ 1 Control valve
√ 2 Pressure Gauge
√ 3 Perpipaan
2
√ 4 Sambungan selang
√ 5 Kondisi kabinet
√ 6 Isi kabinet Hydrant

√ 1 Control valve
√ 2 Pressure Gauge
√ 3 Perpipaan
√ 4 Sambungan selang
√ 5 Kondisi kabinet
√ 6 Isi kabinet Hydrant
3
√ 1 Control valve
√ 2 Pressure Gauge
√ 3 Perpipaan
√ 4 Sambungan selang
√ 5 Kondisi kabinet
√ 6 Isi kabinet Hydrant

√ 1 Control valve
√ 2 Pressure Gauge
√ 3 Perpipaan
√ 4 Sambungan selang
√ 5 Kondisi kabinet
√ 6 Isi kabinet Hydrant
4
√ 1 Control valve
√ 2 Pressure Gauge
√ 3 Perpipaan
√ 4 Sambungan selang
√ 5 Kondisi kabinet
√ 6 Isi kabinet Hydrant
3
√ 1 Control valve
√ 2 Pressure Gauge
√ 3 Perpipaan
√ 4 Sambungan selang
√ 5 Kondisi kabinet

5
 √ 6 Isi kabinet Hydrant
5
√
√
√
√ BULAN: JAN FEB
√
No Ceklist Item
√
1 Control valve
√ 2 Pressure Gauge
√ 3 Perpipaan
√ 4 Sambungan selang
√ 5 Kondisi kabinet
√ 6 Isi kabinet Hydrant
√
6 1 Control valve
√ 2 Pressure Gauge
√ 3 Perpipaan
√ 4 Sambungan selang
√ 5 Kondisi kabinet
√ 6 Isi kabinet Hydrant
√
1 Control valve
√ 2 Pressure Gauge
√ 3 Perpipaan
√ 4 Sambungan selang
√ 5 Kondisi kabinet
√ 6 Isi kabinet Hydrant
√
7 1 Control valve
√ 2 Pressure Gauge
√ 3 Perpipaan
√ 4 Sambungan selang
√ 5 Kondisi kabinet
√ 6 Isi kabinet Hydrant
√

√
√
√
√
√
√
8
8
√
√
√
√
√
√
 INSPEKSI HYDRANT SETIAP 30 HARI

MAR APR MEI JUN JUL AGS SEP OKT NOV DES

Ceklist Item Lokasi Hydrant Lantai Gedung

alve

n
Isolasi paru
an selang

1
alve
Gauge
n
Belakang isolasi paru
an selang
abinet
t Hydrant
3
alve
Gauge
n
Klinik anak
an selang
abinet
t Hydrant
2
alve
Gauge
n
Connecting bedah umum
an selang
abinet
t Hydrant

INSPEKSI HYDRANT SETIAP 30 HARI

MAR APR MEI JUN JUL AGS SEP OKT NOV DES

Ceklist Item Lokasi Hydrant Lantai Gedung

alve

n
Poli DM
an selang

2
alve
Gauge
n
Depan VK 3 2
an selang
abinet
t Hydrant

alve
Gauge
n
ICU covid 1
an selang
abinet
t Hydrant

INSPEKSI HYDRANT SETIAP 30 HARI

MAR APR MEI JUN JUL AGS SEP OKT NOV DES

Ceklist Item Lokasi Hydrant Lantai Gedung

alve

n
Lobby
an selang

alve
Gauge

Depan UGD (Lama)

n
Depan UGD (Lama)
an selang
abinet
t Hydrant

alve
Gauge
n
Samping WTP
an selang
abinet
t Hydrant

alve
Gauge
n Luar
Depan Masjid 1
an selang Gedung
abinet
t Hydrant

alve
Gauge
n
an selang
abinet
t Hydrant

alve
Gauge
n
Parkir Mobil
an selang
abinet
t Hydrant

alve
Gauge
n
an selang
abinet
t Hydrant

INSPEKSI HYDRANT SETIAP 30 HARI

 MAR APR MEI JUN JUL AGS SEP OKT NOV DES

Ceklist Item Lokasi Hydrant Lantai Gedung

alve

n
an selang

alve
Gauge
n
an selang
abinet
t Hydrant

alve
Gauge
n
an selang
abinet
t Hydrant
Luar
Parkir Gedung 3&4 1
Gedung
alve
Gauge
n
an selang
abinet
t Hydrant

alve
Gauge
n
an selang
abinet
t Hydrant

alve
Gauge
n
an selang
abinet
t Hydrant

INSPEKSI HYDRANT SETIAP 30 HARI

MAR APR MEI JUN JUL AGS SEP OKT NOV DES

Ceklist Item Lokasi Hydrant Lantai Gedung

alve

n
Selasar Linen 1
an selang

alve
Gauge
n
Depan R. Control 2
an selang
abinet
t Hydrant
4 (Linen)
alve
Gauge
n
R. Farmasi 3
an selang
abinet
t Hydrant

alve
Gauge
n
Depan Gudang Galon Gizi 4
an selang
abinet
t Hydrant
 Paraf
K3RS

KONDISI
Baik Rusak
√
√
√
√
√
√

√
√
√
√
√
√

√
√
√
√
√
√

√
√
√
√
√
√

Paraf
K3RS

KONDISI
Baik Rusak
√
√
√
√
√
√

√
√
√
√
√
√

√
√
√
√
√
√

Paraf
K3RS

KONDISI
Baik Rusak
√
√
√
√
√
√

√
√
√
√
√
√

√
√
√
√
√
√

√
√
√
√
√
√

√
√
√
√
√
√

√
√
√
√
√
√

√
√
√
√
√
√

Paraf
K3RS
 Paraf
K3RS

KONDISI
Baik Rusak
√
√
√
√
√
√

√
√
√
√
√
√

√
√
√
√
√
√

√
√
√
√
√
√

√
√
√
√
√
√

√
√
√
√
√
√

Paraf
K3RS

KONDISI
Baik Rusak
√
√
√
√
√
√

√
√
√
√
√
√

√
√
√
√
√
√

√
√
√
√
√
√
 INSPEKSI HYDRANT SETIAP 30 HARI

BULAN: JAN FEB MAR APR MEI JUN JUL AGS

No Ceklist Item Lokasi Hydrant

1 Control valve
2 Pressure Gauge
3 Perpipaan
Klinik orthopedi
4 Sambungan selang
5 Kondisi kabinet
6 Isi kabinet Hydrant

1 Control valve
2 Pressure Gauge
3 Perpipaan
Depan pendaftaran BPJS
4 Sambungan selang
5 Kondisi kabinet
6 Isi kabinet Hydrant

1 Control valve
2 Pressure Gauge
3 Perpipaan
Depan toilet belakang IGD lama
4 Sambungan selang
5 Kondisi kabinet
6 Isi kabinet Hydrant

1 Control valve
2 Pressure Gauge
3 Perpipaan IGD lama (Kondisi terhalang baby
4 Sambungan selang incubator)
5 Kondisi kabinet
6 Isi kabinet Hydrant

INSPEKSI HYDRANT SETIAP 30 HARI

BULAN: JAN FEB MAR APR MEI JUN JUL AGS

No Ceklist Item Lokasi Hydrant

 1 Control valve
2 Pressure Gauge
3 Perpipaan
Depan poliklinik rehab medik
4 Sambungan selang
5 Kondisi kabinet
6 Isi kabinet Hydrant

1 Control valve
2 Pressure Gauge
3 Perpipaan
Aula komite medik
4 Sambungan selang
5 Kondisi kabinet
6 Isi kabinet Hydrant

1 Control valve
2 Pressure Gauge
3 Perpipaan
Rekam medik
4 Sambungan selang
5 Kondisi kabinet
6 Isi kabinet Hydrant

INSPEKSI HYDRANT SETIAP 30 HARI

BULAN: JAN FEB MAR APR MEI JUN JUL AGS

No Ceklist Item Lokasi Hydrant

1 Control valve
2 Pressure Gauge
3 Perpipaan
Wing covid
4 Sambungan selang
5 Kondisi kabinet
6 Isi kabinet Hydrant

1 Control valve
2 Pressure Gauge

Belakang wing covid

 3 Perpipaan
Belakang wing covid
4 Sambungan selang
5 Kondisi kabinet
6 Isi kabinet Hydrant

1 Control valve
2 Pressure Gauge
3 Perpipaan
Poli B20
4 Sambungan selang
5 Kondisi kabinet
6 Isi kabinet Hydrant

1 Control valve
2 Pressure Gauge
3 Perpipaan
Ruang RO
4 Sambungan selang
5 Kondisi kabinet
6 Isi kabinet Hydrant

INSPEKSI HYDRANT SETIAP 30 HARI

BULAN: JAN FEB MAR APR MEI JUN JUL AGS

No Ceklist Item Lokasi Hydrant

1 Control valve
2 Pressure Gauge
3 Perpipaan
IGD Baru
4 Sambungan selang
5 Kondisi kabinet
6 Isi kabinet Hydrant

1 Control valve
2 Pressure Gauge
3 Perpipaan
R. Radiologi
4 Sambungan selang
5 Kondisi kabinet
6 Isi kabinet Hydrant

1 Control valve
2 Pressure Gauge
3 Perpipaan
Laboratorium
4 Sambungan selang
 Laboratorium

5 Kondisi kabinet
6 Isi kabinet Hydrant

1 Control valve
2 Pressure Gauge
3 Perpipaan
PICU
4 Sambungan selang
5 Kondisi kabinet
6 Isi kabinet Hydrant

1 Control valve
2 Pressure Gauge
3 Perpipaan
Dalam R. OK
4 Sambungan selang
5 Kondisi kabinet
6 Isi kabinet Hydrant

1 Control valve
2 Pressure Gauge
3 Perpipaan
Dalam R. CSSD
4 Sambungan selang
5 Kondisi kabinet
6 Isi kabinet Hydrant

1 Control valve
2 Pressure Gauge
3 Perpipaan
R. Aula Rapat
4 Sambungan selang
5 Kondisi kabinet
6 Isi kabinet Hydrant

1 Control valve
2 Pressure Gauge
3 Perpipaan
R. Management
4 Sambungan selang
5 Kondisi kabinet
6 Isi kabinet Hydrant

1 Control valve
2 Pressure Gauge
3 Perpipaan
Nurse Station
4 Sambungan selang
5 Kondisi kabinet
 Nurse Station

6 Isi kabinet Hydrant

1 Control valve
2 Pressure Gauge
3 Perpipaan
Nurse Station
4 Sambungan selang
5 Kondisi kabinet
6 Isi kabinet Hydrant

1 Control valve
2 Pressure Gauge
3 Perpipaan
Nurse Station
4 Sambungan selang
5 Kondisi kabinet
6 Isi kabinet Hydrant

1 Control valve
2 Pressure Gauge
3 Perpipaan
Nurse Station
4 Sambungan selang
5 Kondisi kabinet
6 Isi kabinet Hydrant

1 Control valve
2 Pressure Gauge
3 Perpipaan
Nurse Station (R. Rawat VIP)
4 Sambungan selang
5 Kondisi kabinet
6 Isi kabinet Hydrant

1 Control valve
2 Pressure Gauge
3 Perpipaan
Nurse Station (R. Rawat VIP)
4 Sambungan selang
5 Kondisi kabinet
6 Isi kabinet Hydrant

1 Control valve
2 Pressure Gauge
3 Perpipaan
4 Sambungan selang
5 Kondisi kabinet
6 Isi kabinet Hydrant
Aula Besar
 Aula Besar
1 Control valve
2 Pressure Gauge
3 Perpipaan
4 Sambungan selang
5 Kondisi kabinet
6 Isi kabinet Hydrant
ARI Paraf
K3RS
SEP OKT NOV DES BULAN: JAN FEB
KONDISI
Lantai Gedung No Ceklist Item
Baik Rusak
√ 1 Control valve
√ 2 Pressure Gauge
√ 3 Perpipaan
√ 4 Sambungan selang
√ 5 Kondisi kabinet
√ 6 Isi kabinet Hydrant
2
√ 1 Control valve
√ 2 Pressure Gauge
√ 3 Perpipaan
√ 4 Sambungan selang
√ 5 Kondisi kabinet
√ 6 Isi kabinet Hydrant
1
√ 1 Control valve
√ 2 Pressure Gauge
√ 3 Perpipaan
√ 4 Sambungan selang
√ 5 Kondisi kabinet
√ 6 Isi kabinet Hydrant
1
√ 1 Control valve
√ 2 Pressure Gauge
√ 3 Perpipaan
√ 4 Sambungan selang
√ 5 Kondisi kabinet
√ 6 Isi kabinet Hydrant

ARI Paraf
K3RS
SEP OKT NOV DES BULAN: JAN FEB
KONDISI
Lantai Gedung No Ceklist Item
Baik Rusak
 √ 1 Control valve
√ 2 Pressure Gauge
√ 3 Perpipaan
1
√ 4 Sambungan selang
√ 5 Kondisi kabinet
√ 6 Isi kabinet Hydrant

√ 1 Control valve
√ 2 Pressure Gauge
√ 3 Perpipaan
5 2
√ 4 Sambungan selang
√ 5 Kondisi kabinet
√ 6 Isi kabinet Hydrant

√ 1 Control valve
√ 2 Pressure Gauge
√ 3 Perpipaan
2
√ 4 Sambungan selang
√ 5 Kondisi kabinet
√ 6 Isi kabinet Hydrant

ARI Paraf
K3RS
SEP OKT NOV DES BULAN: JAN FEB
KONDISI
Lantai Gedung No Ceklist Item
Baik Rusak
√ 1 Control valve
√ 2 Pressure Gauge
√ 3 Perpipaan
√ 4 Sambungan selang
√ 5 Kondisi kabinet
√ 6 Isi kabinet Hydrant
1
√ 1 Control valve
√ 2 Pressure Gauge
 1

√ 3 Perpipaan
√ 4 Sambungan selang
√ 5 Kondisi kabinet
√ 6 Isi kabinet Hydrant
4
√ 1 Control valve
√ 2 Pressure Gauge
√ 3 Perpipaan
√ 4 Sambungan selang
√ 5 Kondisi kabinet
√ 6 Isi kabinet Hydrant
2
√ 1 Control valve
√ 2 Pressure Gauge
√ 3 Perpipaan
√ 4 Sambungan selang
√ 5 Kondisi kabinet
√ 6 Isi kabinet Hydrant

1 Control valve
2 Pressure Gauge
ARI Paraf
K3RS 3 Perpipaan
SEP OKT NOV DES 4 Sambungan selang
KONDISI 5 Kondisi kabinet
Lantai Gedung
Baik Rusak 6 Isi kabinet Hydrant
√
√ 1 Control valve
√ 2 Pressure Gauge
√ 3 Perpipaan
√ 4 Sambungan selang
√ 5 Kondisi kabinet
6 Isi kabinet Hydrant
√
√ 1 Control valve
√ 2 Pressure Gauge
1
√ 3 Perpipaan
√ 4 Sambungan selang
√ 5 Kondisi kabinet
6 Isi kabinet Hydrant
√
√
√
√
 √ BULAN: JAN FEB
√
No Ceklist Item

√ 1 Control valve
√ 2 Pressure Gauge
√ 3 Perpipaan
2
√ 4 Sambungan selang
√ 5 Kondisi kabinet
√ 6 Isi kabinet Hydrant

√ 1 Control valve
√ 2 Pressure Gauge
√ 3 Perpipaan
√ 4 Sambungan selang
√ 5 Kondisi kabinet
√ 6 Isi kabinet Hydrant
3
√ 1 Control valve
√ 2 Pressure Gauge
√ 3 Perpipaan
√ 4 Sambungan selang
√ 5 Kondisi kabinet
√ 6 Isi kabinet Hydrant

√ 1 Control valve
√ 2 Pressure Gauge
√ 3 Perpipaan
√ 4 Sambungan selang
√ 5 Kondisi kabinet
√ 6 Isi kabinet Hydrant
4
√ 1 Control valve
√ 2 Pressure Gauge
√ 3 Perpipaan
√ 4 Sambungan selang
√ 5 Kondisi kabinet
√ 6 Isi kabinet Hydrant
3
√ 1 Control valve
√ 2 Pressure Gauge
√ 3 Perpipaan
√ 4 Sambungan selang
√ 5 Kondisi kabinet

5
 √ 6 Isi kabinet Hydrant
5
√
√
√
√ BULAN: JAN FEB
√
No Ceklist Item
√
1 Control valve
√ 2 Pressure Gauge
√ 3 Perpipaan
√ 4 Sambungan selang
√ 5 Kondisi kabinet
√ 6 Isi kabinet Hydrant
√
6 1 Control valve
√ 2 Pressure Gauge
√ 3 Perpipaan
√ 4 Sambungan selang
√ 5 Kondisi kabinet
√ 6 Isi kabinet Hydrant
√
1 Control valve
√ 2 Pressure Gauge
√ 3 Perpipaan
√ 4 Sambungan selang
√ 5 Kondisi kabinet
√ 6 Isi kabinet Hydrant
√
7 1 Control valve
√ 2 Pressure Gauge
√ 3 Perpipaan
√ 4 Sambungan selang
√ 5 Kondisi kabinet
√ 6 Isi kabinet Hydrant
√

√
√
√
√
√
√
8
8
√
√
√
√
√
√
 INSPEKSI HYDRANT SETIAP 30 HARI

MAR APR MEI JUN JUL AGS SEP OKT NOV DES

Ceklist Item Lokasi Hydrant Lantai Gedung

alve

n
Isolasi paru
an selang

1
alve
Gauge
n
Belakang isolasi paru
an selang
abinet
t Hydrant
3
alve
Gauge
n
Klinik anak
an selang
abinet
t Hydrant
2
alve
Gauge
n
Connecting bedah umum
an selang
abinet
t Hydrant

INSPEKSI HYDRANT SETIAP 30 HARI

MAR APR MEI JUN JUL AGS SEP OKT NOV DES

Ceklist Item Lokasi Hydrant Lantai Gedung

alve

n
Poli DM
an selang

2
alve
Gauge
n
Depan VK 3 2
an selang
abinet
t Hydrant

alve
Gauge
n
ICU covid 1
an selang
abinet
t Hydrant

INSPEKSI HYDRANT SETIAP 30 HARI

MAR APR MEI JUN JUL AGS SEP OKT NOV DES

Ceklist Item Lokasi Hydrant Lantai Gedung

alve

n
Lobby
an selang

alve
Gauge

Depan UGD (Lama)

n
Depan UGD (Lama)
an selang
abinet
t Hydrant

alve
Gauge
n
Samping WTP
an selang
abinet
t Hydrant

alve
Gauge
n Luar
Depan Masjid 1
an selang Gedung
abinet
t Hydrant

alve
Gauge
n
an selang
abinet
t Hydrant

alve
Gauge
n
Parkir Mobil
an selang
abinet
t Hydrant

alve
Gauge
n
an selang
abinet
t Hydrant

INSPEKSI HYDRANT SETIAP 30 HARI

 MAR APR MEI JUN JUL AGS SEP OKT NOV DES

Ceklist Item Lokasi Hydrant Lantai Gedung

alve

n
an selang

alve
Gauge
n
an selang
abinet
t Hydrant

alve
Gauge
n
an selang
abinet
t Hydrant
Luar
Parkir Gedung 3&4 1
Gedung
alve
Gauge
n
an selang
abinet
t Hydrant

alve
Gauge
n
an selang
abinet
t Hydrant

alve
Gauge
n
an selang
abinet
t Hydrant

INSPEKSI HYDRANT SETIAP 30 HARI

MAR APR MEI JUN JUL AGS SEP OKT NOV DES

Ceklist Item Lokasi Hydrant Lantai Gedung

alve

n
Selasar Linen 1
an selang

alve
Gauge
n
Depan R. Control 2
an selang
abinet
t Hydrant
4 (Linen)
alve
Gauge
n
R. Farmasi 3
an selang
abinet
t Hydrant

alve
Gauge
n
Depan Gudang Galon Gizi 4
an selang
abinet
t Hydrant
 Paraf
K3RS

KONDISI
Baik Rusak
√
√
√
√
√
√

√
√
√
√
√
√

√
√
√
√
√
√

√
√
√
√
√
√

Paraf
K3RS

KONDISI
Baik Rusak
√
√
√
√
√
√

√
√
√
√
√
√

√
√
√
√
√
√

Paraf
K3RS

KONDISI
Baik Rusak
√
√
√
√
√
√

√
√
√
√
√
√

√
√
√
√
√
√

√
√
√
√
√
√

√
√
√
√
√
√

√
√
√
√
√
√

√
√
√
√
√
√

Paraf
K3RS
 Paraf
K3RS

KONDISI
Baik Rusak
√
√
√
√
√
√

√
√
√
√
√
√

√
√
√
√
√
√

√
√
√
√
√
√

√
√
√
√
√
√

√
√
√
√
√
√

Paraf
K3RS

KONDISI
Baik Rusak
√
√
√
√
√
√

√
√
√
√
√
√

√
√
√
√
√
√

√
√
√
√
√
√
 INSPEKSI HYDRANT SETIAP 30 HARI

BULAN: JAN FEB MAR APR MEI JUN JUL AGS

No Ceklist Item Lokasi Hydrant

1 Control valve
2 Pressure Gauge
3 Perpipaan
Klinik orthopedi
4 Sambungan selang
5 Kondisi kabinet
6 Isi kabinet Hydrant

1 Control valve
2 Pressure Gauge
3 Perpipaan
Depan pendaftaran BPJS
4 Sambungan selang
5 Kondisi kabinet
6 Isi kabinet Hydrant

1 Control valve
2 Pressure Gauge
3 Perpipaan
Depan toilet belakang IGD lama
4 Sambungan selang
5 Kondisi kabinet
6 Isi kabinet Hydrant

1 Control valve
2 Pressure Gauge
3 Perpipaan IGD lama (Kondisi terhalang baby
4 Sambungan selang incubator)
5 Kondisi kabinet
6 Isi kabinet Hydrant

INSPEKSI HYDRANT SETIAP 30 HARI

BULAN: JAN FEB MAR APR MEI JUN JUL AGS

No Ceklist Item Lokasi Hydrant

 1 Control valve
2 Pressure Gauge
3 Perpipaan
Depan poliklinik rehab medik
4 Sambungan selang
5 Kondisi kabinet
6 Isi kabinet Hydrant

1 Control valve
2 Pressure Gauge
3 Perpipaan
Aula komite medik
4 Sambungan selang
5 Kondisi kabinet
6 Isi kabinet Hydrant

1 Control valve
2 Pressure Gauge
3 Perpipaan
Rekam medik
4 Sambungan selang
5 Kondisi kabinet
6 Isi kabinet Hydrant

INSPEKSI HYDRANT SETIAP 30 HARI

BULAN: JAN FEB MAR APR MEI JUN JUL AGS

No Ceklist Item Lokasi Hydrant

1 Control valve
2 Pressure Gauge
3 Perpipaan
Wing covid
4 Sambungan selang
5 Kondisi kabinet
6 Isi kabinet Hydrant

1 Control valve
2 Pressure Gauge

Belakang wing covid

 3 Perpipaan
Belakang wing covid
4 Sambungan selang
5 Kondisi kabinet
6 Isi kabinet Hydrant

1 Control valve
2 Pressure Gauge
3 Perpipaan
Poli B20
4 Sambungan selang
5 Kondisi kabinet
6 Isi kabinet Hydrant

1 Control valve
2 Pressure Gauge
3 Perpipaan
Ruang RO
4 Sambungan selang
5 Kondisi kabinet
6 Isi kabinet Hydrant

INSPEKSI HYDRANT SETIAP 30 HARI

BULAN: JAN FEB MAR APR MEI JUN JUL AGS

No Ceklist Item Lokasi Hydrant

1 Control valve
2 Pressure Gauge
3 Perpipaan
IGD Baru
4 Sambungan selang
5 Kondisi kabinet
6 Isi kabinet Hydrant

1 Control valve
2 Pressure Gauge
3 Perpipaan
R. Radiologi
4 Sambungan selang
5 Kondisi kabinet
6 Isi kabinet Hydrant

1 Control valve
2 Pressure Gauge
3 Perpipaan
Laboratorium
4 Sambungan selang
 Laboratorium

5 Kondisi kabinet
6 Isi kabinet Hydrant

1 Control valve
2 Pressure Gauge
3 Perpipaan
PICU
4 Sambungan selang
5 Kondisi kabinet
6 Isi kabinet Hydrant

1 Control valve
2 Pressure Gauge
3 Perpipaan
Dalam R. OK
4 Sambungan selang
5 Kondisi kabinet
6 Isi kabinet Hydrant

1 Control valve
2 Pressure Gauge
3 Perpipaan
Dalam R. CSSD
4 Sambungan selang
5 Kondisi kabinet
6 Isi kabinet Hydrant

1 Control valve
2 Pressure Gauge
3 Perpipaan
R. Aula Rapat
4 Sambungan selang
5 Kondisi kabinet
6 Isi kabinet Hydrant

1 Control valve
2 Pressure Gauge
3 Perpipaan
R. Management
4 Sambungan selang
5 Kondisi kabinet
6 Isi kabinet Hydrant

1 Control valve
2 Pressure Gauge
3 Perpipaan
Nurse Station
4 Sambungan selang
5 Kondisi kabinet
 Nurse Station

6 Isi kabinet Hydrant

1 Control valve
2 Pressure Gauge
3 Perpipaan
Nurse Station
4 Sambungan selang
5 Kondisi kabinet
6 Isi kabinet Hydrant

1 Control valve
2 Pressure Gauge
3 Perpipaan
Nurse Station
4 Sambungan selang
5 Kondisi kabinet
6 Isi kabinet Hydrant

1 Control valve
2 Pressure Gauge
3 Perpipaan
Nurse Station
4 Sambungan selang
5 Kondisi kabinet
6 Isi kabinet Hydrant

1 Control valve
2 Pressure Gauge
3 Perpipaan
Nurse Station (R. Rawat VIP)
4 Sambungan selang
5 Kondisi kabinet
6 Isi kabinet Hydrant

1 Control valve
2 Pressure Gauge
3 Perpipaan
Nurse Station (R. Rawat VIP)
4 Sambungan selang
5 Kondisi kabinet
6 Isi kabinet Hydrant

1 Control valve
2 Pressure Gauge
3 Perpipaan
4 Sambungan selang
5 Kondisi kabinet
6 Isi kabinet Hydrant
Aula Besar
 Aula Besar
1 Control valve
2 Pressure Gauge
3 Perpipaan
4 Sambungan selang
5 Kondisi kabinet
6 Isi kabinet Hydrant
ARI Paraf
K3RS
SEP OKT NOV DES BULAN: JAN FEB
KONDISI
Lantai Gedung No Ceklist Item
Baik Rusak
√ 1 Control valve
√ 2 Pressure Gauge
√ 3 Perpipaan
√ 4 Sambungan selang
√ 5 Kondisi kabinet
√ 6 Isi kabinet Hydrant
2
√ 1 Control valve
√ 2 Pressure Gauge
√ 3 Perpipaan
√ 4 Sambungan selang
√ 5 Kondisi kabinet
√ 6 Isi kabinet Hydrant
1
√ 1 Control valve
√ 2 Pressure Gauge
√ 3 Perpipaan
√ 4 Sambungan selang
√ 5 Kondisi kabinet
√ 6 Isi kabinet Hydrant
1
√ 1 Control valve
√ 2 Pressure Gauge
√ 3 Perpipaan
√ 4 Sambungan selang
√ 5 Kondisi kabinet
√ 6 Isi kabinet Hydrant

ARI Paraf
K3RS
SEP OKT NOV DES BULAN: JAN FEB
KONDISI
Lantai Gedung No Ceklist Item
Baik Rusak
 √ 1 Control valve
√ 2 Pressure Gauge
√ 3 Perpipaan
1
√ 4 Sambungan selang
√ 5 Kondisi kabinet
√ 6 Isi kabinet Hydrant

√ 1 Control valve
√ 2 Pressure Gauge
√ 3 Perpipaan
5 2
√ 4 Sambungan selang
√ 5 Kondisi kabinet
√ 6 Isi kabinet Hydrant

√ 1 Control valve
√ 2 Pressure Gauge
√ 3 Perpipaan
2
√ 4 Sambungan selang
√ 5 Kondisi kabinet
√ 6 Isi kabinet Hydrant

ARI Paraf
K3RS
SEP OKT NOV DES BULAN: JAN FEB
KONDISI
Lantai Gedung No Ceklist Item
Baik Rusak
√ 1 Control valve
√ 2 Pressure Gauge
√ 3 Perpipaan
√ 4 Sambungan selang
√ 5 Kondisi kabinet
√ 6 Isi kabinet Hydrant
1
√ 1 Control valve
√ 2 Pressure Gauge
 1

√ 3 Perpipaan
√ 4 Sambungan selang
√ 5 Kondisi kabinet
√ 6 Isi kabinet Hydrant
4
√ 1 Control valve
√ 2 Pressure Gauge
√ 3 Perpipaan
√ 4 Sambungan selang
√ 5 Kondisi kabinet
√ 6 Isi kabinet Hydrant
2
√ 1 Control valve
√ 2 Pressure Gauge
√ 3 Perpipaan
√ 4 Sambungan selang
√ 5 Kondisi kabinet
√ 6 Isi kabinet Hydrant

1 Control valve
2 Pressure Gauge
ARI Paraf
K3RS 3 Perpipaan
SEP OKT NOV DES 4 Sambungan selang
KONDISI 5 Kondisi kabinet
Lantai Gedung
Baik Rusak 6 Isi kabinet Hydrant
√
√ 1 Control valve
√ 2 Pressure Gauge
√ 3 Perpipaan
√ 4 Sambungan selang
√ 5 Kondisi kabinet
6 Isi kabinet Hydrant
√
√ 1 Control valve
√ 2 Pressure Gauge
1
√ 3 Perpipaan
√ 4 Sambungan selang
√ 5 Kondisi kabinet
6 Isi kabinet Hydrant
√
√
√
√
 √ BULAN: JAN FEB
√
No Ceklist Item

√ 1 Control valve
√ 2 Pressure Gauge
√ 3 Perpipaan
2
√ 4 Sambungan selang
√ 5 Kondisi kabinet
√ 6 Isi kabinet Hydrant

√ 1 Control valve
√ 2 Pressure Gauge
√ 3 Perpipaan
√ 4 Sambungan selang
√ 5 Kondisi kabinet
√ 6 Isi kabinet Hydrant
3
√ 1 Control valve
√ 2 Pressure Gauge
√ 3 Perpipaan
√ 4 Sambungan selang
√ 5 Kondisi kabinet
√ 6 Isi kabinet Hydrant

√ 1 Control valve
√ 2 Pressure Gauge
√ 3 Perpipaan
√ 4 Sambungan selang
√ 5 Kondisi kabinet
√ 6 Isi kabinet Hydrant
4
√ 1 Control valve
√ 2 Pressure Gauge
√ 3 Perpipaan
√ 4 Sambungan selang
√ 5 Kondisi kabinet
√ 6 Isi kabinet Hydrant
3
√ 1 Control valve
√ 2 Pressure Gauge
√ 3 Perpipaan
√ 4 Sambungan selang
√ 5 Kondisi kabinet

5
 √ 6 Isi kabinet Hydrant
5
√
√
√
√ BULAN: JAN FEB
√
No Ceklist Item
√
1 Control valve
√ 2 Pressure Gauge
√ 3 Perpipaan
√ 4 Sambungan selang
√ 5 Kondisi kabinet
√ 6 Isi kabinet Hydrant
√
6 1 Control valve
√ 2 Pressure Gauge
√ 3 Perpipaan
√ 4 Sambungan selang
√ 5 Kondisi kabinet
√ 6 Isi kabinet Hydrant
√
1 Control valve
√ 2 Pressure Gauge
√ 3 Perpipaan
√ 4 Sambungan selang
√ 5 Kondisi kabinet
√ 6 Isi kabinet Hydrant
√
7 1 Control valve
√ 2 Pressure Gauge
√ 3 Perpipaan
√ 4 Sambungan selang
√ 5 Kondisi kabinet
√ 6 Isi kabinet Hydrant
√

√
√
√
√
√
√
8
8
√
√
√
√
√
√
 INSPEKSI HYDRANT SETIAP 30 HARI

MAR APR MEI JUN JUL AGS SEP OKT NOV DES

Ceklist Item Lokasi Hydrant Lantai Gedung

alve

n
Isolasi paru
an selang

1
alve
Gauge
n
Belakang isolasi paru
an selang
abinet
t Hydrant
3
alve
Gauge
n
Klinik anak
an selang
abinet
t Hydrant
2
alve
Gauge
n
Connecting bedah umum
an selang
abinet
t Hydrant

INSPEKSI HYDRANT SETIAP 30 HARI

MAR APR MEI JUN JUL AGS SEP OKT NOV DES

Ceklist Item Lokasi Hydrant Lantai Gedung

alve

n
Poli DM
an selang

2
alve
Gauge
n
Depan VK 3 2
an selang
abinet
t Hydrant

alve
Gauge
n
ICU covid 1
an selang
abinet
t Hydrant

INSPEKSI HYDRANT SETIAP 30 HARI

MAR APR MEI JUN JUL AGS SEP OKT NOV DES

Ceklist Item Lokasi Hydrant Lantai Gedung

alve

n
Lobby
an selang

alve
Gauge

Depan UGD (Lama)

n
Depan UGD (Lama)
an selang
abinet
t Hydrant

alve
Gauge
n
Samping WTP
an selang
abinet
t Hydrant

alve
Gauge
n Luar
Depan Masjid 1
an selang Gedung
abinet
t Hydrant

alve
Gauge
n
an selang
abinet
t Hydrant

alve
Gauge
n
Parkir Mobil
an selang
abinet
t Hydrant

alve
Gauge
n
an selang
abinet
t Hydrant

INSPEKSI HYDRANT SETIAP 30 HARI

 MAR APR MEI JUN JUL AGS SEP OKT NOV DES

Ceklist Item Lokasi Hydrant Lantai Gedung

alve

n
an selang

alve
Gauge
n
an selang
abinet
t Hydrant

alve
Gauge
n
an selang
abinet
t Hydrant
Luar
Parkir Gedung 3&4 1
Gedung
alve
Gauge
n
an selang
abinet
t Hydrant

alve
Gauge
n
an selang
abinet
t Hydrant

alve
Gauge
n
an selang
abinet
t Hydrant

INSPEKSI HYDRANT SETIAP 30 HARI

MAR APR MEI JUN JUL AGS SEP OKT NOV DES

Ceklist Item Lokasi Hydrant Lantai Gedung

alve

n
Selasar Linen 1
an selang

alve
Gauge
n
Depan R. Control 2
an selang
abinet
t Hydrant
4 (Linen)
alve
Gauge
n
R. Farmasi 3
an selang
abinet
t Hydrant

alve
Gauge
n
Depan Gudang Galon Gizi 4
an selang
abinet
t Hydrant
 Paraf
K3RS

KONDISI
Baik Rusak
√
√
√
√
√
√

√
√
√
√
√
√

√
√
√
√
√
√

√
√
√
√
√
√

Paraf
K3RS

KONDISI
Baik Rusak
√
√
√
√
√
√

√
√
√
√
√
√

√
√
√
√
√
√

Paraf
K3RS

KONDISI
Baik Rusak
√
√
√
√
√
√

√
√
√
√
√
√

√
√
√
√
√
√

√
√
√
√
√
√

√
√
√
√
√
√

√
√
√
√
√
√

√
√
√
√
√
√

Paraf
K3RS
 Paraf
K3RS

KONDISI
Baik Rusak
√
√
√
√
√
√

√
√
√
√
√
√

√
√
√
√
√
√

√
√
√
√
√
√

√
√
√
√
√
√

√
√
√
√
√
√

Paraf
K3RS

KONDISI
Baik Rusak
√
√
√
√
√
√

√
√
√
√
√
√

√
√
√
√
√
√

√
√
√
√
√
√
 INSPEKSI HYDRANT SETIAP 30 HARI

BULAN: JAN FEB MAR APR MEI JUN JUL AGS

No Ceklist Item Lokasi Hydrant

1 Control valve
2 Pressure Gauge
3 Perpipaan
Klinik orthopedi
4 Sambungan selang
5 Kondisi kabinet
6 Isi kabinet Hydrant

1 Control valve
2 Pressure Gauge
3 Perpipaan
Depan pendaftaran BPJS
4 Sambungan selang
5 Kondisi kabinet
6 Isi kabinet Hydrant

1 Control valve
2 Pressure Gauge
3 Perpipaan
Depan toilet belakang IGD lama
4 Sambungan selang
5 Kondisi kabinet
6 Isi kabinet Hydrant

1 Control valve
2 Pressure Gauge
3 Perpipaan IGD lama (Kondisi terhalang baby
4 Sambungan selang incubator)
5 Kondisi kabinet
6 Isi kabinet Hydrant

INSPEKSI HYDRANT SETIAP 30 HARI

BULAN: JAN FEB MAR APR MEI JUN JUL AGS

No Ceklist Item Lokasi Hydrant

 1 Control valve
2 Pressure Gauge
3 Perpipaan
Depan poliklinik rehab medik
4 Sambungan selang
5 Kondisi kabinet
6 Isi kabinet Hydrant

1 Control valve
2 Pressure Gauge
3 Perpipaan
Aula komite medik
4 Sambungan selang
5 Kondisi kabinet
6 Isi kabinet Hydrant

1 Control valve
2 Pressure Gauge
3 Perpipaan
Rekam medik
4 Sambungan selang
5 Kondisi kabinet
6 Isi kabinet Hydrant

INSPEKSI HYDRANT SETIAP 30 HARI

BULAN: JAN FEB MAR APR MEI JUN JUL AGS

No Ceklist Item Lokasi Hydrant

1 Control valve
2 Pressure Gauge
3 Perpipaan
Wing covid
4 Sambungan selang
5 Kondisi kabinet
6 Isi kabinet Hydrant

1 Control valve
2 Pressure Gauge

Belakang wing covid

 3 Perpipaan
Belakang wing covid
4 Sambungan selang
5 Kondisi kabinet
6 Isi kabinet Hydrant

1 Control valve
2 Pressure Gauge
3 Perpipaan
Poli B20
4 Sambungan selang
5 Kondisi kabinet
6 Isi kabinet Hydrant

1 Control valve
2 Pressure Gauge
3 Perpipaan
Ruang RO
4 Sambungan selang
5 Kondisi kabinet
6 Isi kabinet Hydrant

INSPEKSI HYDRANT SETIAP 30 HARI

BULAN: JAN FEB MAR APR MEI JUN JUL AGS

No Ceklist Item Lokasi Hydrant

1 Control valve
2 Pressure Gauge
3 Perpipaan
IGD Baru
4 Sambungan selang
5 Kondisi kabinet
6 Isi kabinet Hydrant

1 Control valve
2 Pressure Gauge
3 Perpipaan
R. Radiologi
4 Sambungan selang
5 Kondisi kabinet
6 Isi kabinet Hydrant

1 Control valve
2 Pressure Gauge
3 Perpipaan
Laboratorium
4 Sambungan selang
 Laboratorium

5 Kondisi kabinet
6 Isi kabinet Hydrant

1 Control valve
2 Pressure Gauge
3 Perpipaan
PICU
4 Sambungan selang
5 Kondisi kabinet
6 Isi kabinet Hydrant

1 Control valve
2 Pressure Gauge
3 Perpipaan
Dalam R. OK
4 Sambungan selang
5 Kondisi kabinet
6 Isi kabinet Hydrant

1 Control valve
2 Pressure Gauge
3 Perpipaan
Dalam R. CSSD
4 Sambungan selang
5 Kondisi kabinet
6 Isi kabinet Hydrant

1 Control valve
2 Pressure Gauge
3 Perpipaan
R. Aula Rapat
4 Sambungan selang
5 Kondisi kabinet
6 Isi kabinet Hydrant

1 Control valve
2 Pressure Gauge
3 Perpipaan
R. Management
4 Sambungan selang
5 Kondisi kabinet
6 Isi kabinet Hydrant

1 Control valve
2 Pressure Gauge
3 Perpipaan
Nurse Station
4 Sambungan selang
5 Kondisi kabinet
 Nurse Station

6 Isi kabinet Hydrant

1 Control valve
2 Pressure Gauge
3 Perpipaan
Nurse Station
4 Sambungan selang
5 Kondisi kabinet
6 Isi kabinet Hydrant

1 Control valve
2 Pressure Gauge
3 Perpipaan
Nurse Station
4 Sambungan selang
5 Kondisi kabinet
6 Isi kabinet Hydrant

1 Control valve
2 Pressure Gauge
3 Perpipaan
Nurse Station
4 Sambungan selang
5 Kondisi kabinet
6 Isi kabinet Hydrant

1 Control valve
2 Pressure Gauge
3 Perpipaan
Nurse Station (R. Rawat VIP)
4 Sambungan selang
5 Kondisi kabinet
6 Isi kabinet Hydrant

1 Control valve
2 Pressure Gauge
3 Perpipaan
Nurse Station (R. Rawat VIP)
4 Sambungan selang
5 Kondisi kabinet
6 Isi kabinet Hydrant

1 Control valve
2 Pressure Gauge
3 Perpipaan
4 Sambungan selang
5 Kondisi kabinet
6 Isi kabinet Hydrant
Aula Besar
 Aula Besar
1 Control valve
2 Pressure Gauge
3 Perpipaan
4 Sambungan selang
5 Kondisi kabinet
6 Isi kabinet Hydrant
ARI Paraf
K3RS
SEP OKT NOV DES BULAN: JAN FEB
KONDISI
Lantai Gedung No Ceklist Item
Baik Rusak
√ 1 Control valve
√ 2 Pressure Gauge
√ 3 Perpipaan
√ 4 Sambungan selang
√ 5 Kondisi kabinet
√ 6 Isi kabinet Hydrant
2
√ 1 Control valve
√ 2 Pressure Gauge
√ 3 Perpipaan
√ 4 Sambungan selang
√ 5 Kondisi kabinet
√ 6 Isi kabinet Hydrant
1
√ 1 Control valve
√ 2 Pressure Gauge
√ 3 Perpipaan
√ 4 Sambungan selang
√ 5 Kondisi kabinet
√ 6 Isi kabinet Hydrant
1
√ 1 Control valve
√ 2 Pressure Gauge
√ 3 Perpipaan
√ 4 Sambungan selang
√ 5 Kondisi kabinet
√ 6 Isi kabinet Hydrant

ARI Paraf
K3RS
SEP OKT NOV DES BULAN: JAN FEB
KONDISI
Lantai Gedung No Ceklist Item
Baik Rusak
 √ 1 Control valve
√ 2 Pressure Gauge
√ 3 Perpipaan
1
√ 4 Sambungan selang
√ 5 Kondisi kabinet
√ 6 Isi kabinet Hydrant

√ 1 Control valve
√ 2 Pressure Gauge
√ 3 Perpipaan
5 2
√ 4 Sambungan selang
√ 5 Kondisi kabinet
√ 6 Isi kabinet Hydrant

√ 1 Control valve
√ 2 Pressure Gauge
√ 3 Perpipaan
2
√ 4 Sambungan selang
√ 5 Kondisi kabinet
√ 6 Isi kabinet Hydrant

ARI Paraf
K3RS
SEP OKT NOV DES BULAN: JAN FEB
KONDISI
Lantai Gedung No Ceklist Item
Baik Rusak
√ 1 Control valve
√ 2 Pressure Gauge
√ 3 Perpipaan
√ 4 Sambungan selang
√ 5 Kondisi kabinet
√ 6 Isi kabinet Hydrant
1
√ 1 Control valve
√ 2 Pressure Gauge
 1

√ 3 Perpipaan
√ 4 Sambungan selang
√ 5 Kondisi kabinet
√ 6 Isi kabinet Hydrant
4
√ 1 Control valve
√ 2 Pressure Gauge
√ 3 Perpipaan
√ 4 Sambungan selang
√ 5 Kondisi kabinet
√ 6 Isi kabinet Hydrant
2
√ 1 Control valve
√ 2 Pressure Gauge
√ 3 Perpipaan
√ 4 Sambungan selang
√ 5 Kondisi kabinet
√ 6 Isi kabinet Hydrant

1 Control valve
2 Pressure Gauge
ARI Paraf
K3RS 3 Perpipaan
SEP OKT NOV DES 4 Sambungan selang
KONDISI 5 Kondisi kabinet
Lantai Gedung
Baik Rusak 6 Isi kabinet Hydrant
√
√ 1 Control valve
√ 2 Pressure Gauge
√ 3 Perpipaan
√ 4 Sambungan selang
√ 5 Kondisi kabinet
6 Isi kabinet Hydrant
√
√ 1 Control valve
√ 2 Pressure Gauge
1
√ 3 Perpipaan
√ 4 Sambungan selang
√ 5 Kondisi kabinet
6 Isi kabinet Hydrant
√
√
√
√
 √ BULAN: JAN FEB
√
No Ceklist Item

√ 1 Control valve
√ 2 Pressure Gauge
√ 3 Perpipaan
2
√ 4 Sambungan selang
√ 5 Kondisi kabinet
√ 6 Isi kabinet Hydrant

√ 1 Control valve
√ 2 Pressure Gauge
√ 3 Perpipaan
√ 4 Sambungan selang
√ 5 Kondisi kabinet
√ 6 Isi kabinet Hydrant
3
√ 1 Control valve
√ 2 Pressure Gauge
√ 3 Perpipaan
√ 4 Sambungan selang
√ 5 Kondisi kabinet
√ 6 Isi kabinet Hydrant

√ 1 Control valve
√ 2 Pressure Gauge
√ 3 Perpipaan
√ 4 Sambungan selang
√ 5 Kondisi kabinet
√ 6 Isi kabinet Hydrant
4
√ 1 Control valve
√ 2 Pressure Gauge
√ 3 Perpipaan
√ 4 Sambungan selang
√ 5 Kondisi kabinet
√ 6 Isi kabinet Hydrant
3
√ 1 Control valve
√ 2 Pressure Gauge
√ 3 Perpipaan
√ 4 Sambungan selang
√ 5 Kondisi kabinet

5
 √ 6 Isi kabinet Hydrant
5
√
√
√
√ BULAN: JAN FEB
√
No Ceklist Item
√
1 Control valve
√ 2 Pressure Gauge
√ 3 Perpipaan
√ 4 Sambungan selang
√ 5 Kondisi kabinet
√ 6 Isi kabinet Hydrant
√
6 1 Control valve
√ 2 Pressure Gauge
√ 3 Perpipaan
√ 4 Sambungan selang
√ 5 Kondisi kabinet
√ 6 Isi kabinet Hydrant
√
1 Control valve
√ 2 Pressure Gauge
√ 3 Perpipaan
√ 4 Sambungan selang
√ 5 Kondisi kabinet
√ 6 Isi kabinet Hydrant
√
7 1 Control valve
√ 2 Pressure Gauge
√ 3 Perpipaan
√ 4 Sambungan selang
√ 5 Kondisi kabinet
√ 6 Isi kabinet Hydrant
√

√
√
√
√
√
√
8
8
√
√
√
√
√
√
 INSPEKSI HYDRANT SETIAP 30 HARI

MAR APR MEI JUN JUL AGS SEP OKT NOV DES

Ceklist Item Lokasi Hydrant Lantai Gedung

alve

n
Isolasi paru
an selang

1
alve
Gauge
n
Belakang isolasi paru
an selang
abinet
t Hydrant
3
alve
Gauge
n
Klinik anak
an selang
abinet
t Hydrant
2
alve
Gauge
n
Connecting bedah umum
an selang
abinet
t Hydrant

INSPEKSI HYDRANT SETIAP 30 HARI

MAR APR MEI JUN JUL AGS SEP OKT NOV DES

Ceklist Item Lokasi Hydrant Lantai Gedung

alve

n
Poli DM
an selang

2
alve
Gauge
n
Depan VK 3 2
an selang
abinet
t Hydrant

alve
Gauge
n
ICU covid 1
an selang
abinet
t Hydrant

INSPEKSI HYDRANT SETIAP 30 HARI

MAR APR MEI JUN JUL AGS SEP OKT NOV DES

Ceklist Item Lokasi Hydrant Lantai Gedung

alve

n
Lobby
an selang

alve
Gauge

Depan UGD (Lama)

n
Depan UGD (Lama)
an selang
abinet
t Hydrant

alve
Gauge
n
Samping WTP
an selang
abinet
t Hydrant

alve
Gauge
n Luar
Depan Masjid 1
an selang Gedung
abinet
t Hydrant

alve
Gauge
n
an selang
abinet
t Hydrant

alve
Gauge
n
Parkir Mobil
an selang
abinet
t Hydrant

alve
Gauge
n
an selang
abinet
t Hydrant

INSPEKSI HYDRANT SETIAP 30 HARI

 MAR APR MEI JUN JUL AGS SEP OKT NOV DES

Ceklist Item Lokasi Hydrant Lantai Gedung

alve

n
an selang

alve
Gauge
n
an selang
abinet
t Hydrant

alve
Gauge
n
an selang
abinet
t Hydrant
Luar
Parkir Gedung 3&4 1
Gedung
alve
Gauge
n
an selang
abinet
t Hydrant

alve
Gauge
n
an selang
abinet
t Hydrant

alve
Gauge
n
an selang
abinet
t Hydrant

INSPEKSI HYDRANT SETIAP 30 HARI

MAR APR MEI JUN JUL AGS SEP OKT NOV DES

Ceklist Item Lokasi Hydrant Lantai Gedung

alve

n
Selasar Linen 1
an selang

alve
Gauge
n
Depan R. Control 2
an selang
abinet
t Hydrant
4 (Linen)
alve
Gauge
n
R. Farmasi 3
an selang
abinet
t Hydrant

alve
Gauge
n
Depan Gudang Galon Gizi 4
an selang
abinet
t Hydrant
 Paraf
K3RS

KONDISI
Baik Rusak
√
√
√
√
√
√

√
√
√
√
√
√

√
√
√
√
√
√

√
√
√
√
√
√

Paraf
K3RS

KONDISI
Baik Rusak
√
√
√
√
√
√

√
√
√
√
√
√

√
√
√
√
√
√

Paraf
K3RS

KONDISI
Baik Rusak
√
√
√
√
√
√

√
√
√
√
√
√

√
√
√
√
√
√

√
√
√
√
√
√

√
√
√
√
√
√

√
√
√
√
√
√

√
√
√
√
√
√

Paraf
K3RS
 Paraf
K3RS

KONDISI
Baik Rusak
√
√
√
√
√
√

√
√
√
√
√
√

√
√
√
√
√
√

√
√
√
√
√
√

√
√
√
√
√
√

√
√
√
√
√
√

Paraf
K3RS

KONDISI
Baik Rusak
√
√
√
√
√
√

√
√
√
√
√
√

√
√
√
√
√
√

√
√
√
√
√
√
 INSPEKSI HYDRANT SETIAP 30 HARI

BULAN: JAN FEB MAR APR MEI JUN JUL AGS

No Ceklist Item Lokasi Hydrant

1 Control valve
2 Pressure Gauge
3 Perpipaan
Klinik orthopedi
4 Sambungan selang
5 Kondisi kabinet
6 Isi kabinet Hydrant

1 Control valve
2 Pressure Gauge
3 Perpipaan
Depan pendaftaran BPJS
4 Sambungan selang
5 Kondisi kabinet
6 Isi kabinet Hydrant

1 Control valve
2 Pressure Gauge
3 Perpipaan
Depan toilet belakang IGD lama
4 Sambungan selang
5 Kondisi kabinet
6 Isi kabinet Hydrant

1 Control valve
2 Pressure Gauge
3 Perpipaan IGD lama (Kondisi terhalang baby
4 Sambungan selang incubator)
5 Kondisi kabinet
6 Isi kabinet Hydrant

INSPEKSI HYDRANT SETIAP 30 HARI

BULAN: JAN FEB MAR APR MEI JUN JUL AGS

No Ceklist Item Lokasi Hydrant

 1 Control valve
2 Pressure Gauge
3 Perpipaan
Depan poliklinik rehab medik
4 Sambungan selang
5 Kondisi kabinet
6 Isi kabinet Hydrant

1 Control valve
2 Pressure Gauge
3 Perpipaan
Aula komite medik
4 Sambungan selang
5 Kondisi kabinet
6 Isi kabinet Hydrant

1 Control valve
2 Pressure Gauge
3 Perpipaan
Rekam medik
4 Sambungan selang
5 Kondisi kabinet
6 Isi kabinet Hydrant

INSPEKSI HYDRANT SETIAP 30 HARI

BULAN: JAN FEB MAR APR MEI JUN JUL AGS

No Ceklist Item Lokasi Hydrant

1 Control valve
2 Pressure Gauge
3 Perpipaan
Wing covid
4 Sambungan selang
5 Kondisi kabinet
6 Isi kabinet Hydrant

1 Control valve
2 Pressure Gauge

Belakang wing covid

 3 Perpipaan
Belakang wing covid
4 Sambungan selang
5 Kondisi kabinet
6 Isi kabinet Hydrant

1 Control valve
2 Pressure Gauge
3 Perpipaan
Poli B20
4 Sambungan selang
5 Kondisi kabinet
6 Isi kabinet Hydrant

1 Control valve
2 Pressure Gauge
3 Perpipaan
Ruang RO
4 Sambungan selang
5 Kondisi kabinet
6 Isi kabinet Hydrant

INSPEKSI HYDRANT SETIAP 30 HARI

BULAN: JAN FEB MAR APR MEI JUN JUL AGS

No Ceklist Item Lokasi Hydrant

1 Control valve
2 Pressure Gauge
3 Perpipaan
IGD Baru
4 Sambungan selang
5 Kondisi kabinet
6 Isi kabinet Hydrant

1 Control valve
2 Pressure Gauge
3 Perpipaan
R. Radiologi
4 Sambungan selang
5 Kondisi kabinet
6 Isi kabinet Hydrant

1 Control valve
2 Pressure Gauge
3 Perpipaan
Laboratorium
4 Sambungan selang
 Laboratorium

5 Kondisi kabinet
6 Isi kabinet Hydrant

1 Control valve
2 Pressure Gauge
3 Perpipaan
PICU
4 Sambungan selang
5 Kondisi kabinet
6 Isi kabinet Hydrant

1 Control valve
2 Pressure Gauge
3 Perpipaan
Dalam R. OK
4 Sambungan selang
5 Kondisi kabinet
6 Isi kabinet Hydrant

1 Control valve
2 Pressure Gauge
3 Perpipaan
Dalam R. CSSD
4 Sambungan selang
5 Kondisi kabinet
6 Isi kabinet Hydrant

1 Control valve
2 Pressure Gauge
3 Perpipaan
R. Aula Rapat
4 Sambungan selang
5 Kondisi kabinet
6 Isi kabinet Hydrant

1 Control valve
2 Pressure Gauge
3 Perpipaan
R. Management
4 Sambungan selang
5 Kondisi kabinet
6 Isi kabinet Hydrant

1 Control valve
2 Pressure Gauge
3 Perpipaan
Nurse Station
4 Sambungan selang
5 Kondisi kabinet
 Nurse Station

6 Isi kabinet Hydrant

1 Control valve
2 Pressure Gauge
3 Perpipaan
Nurse Station
4 Sambungan selang
5 Kondisi kabinet
6 Isi kabinet Hydrant

1 Control valve
2 Pressure Gauge
3 Perpipaan
Nurse Station
4 Sambungan selang
5 Kondisi kabinet
6 Isi kabinet Hydrant

1 Control valve
2 Pressure Gauge
3 Perpipaan
Nurse Station
4 Sambungan selang
5 Kondisi kabinet
6 Isi kabinet Hydrant

1 Control valve
2 Pressure Gauge
3 Perpipaan
Nurse Station (R. Rawat VIP)
4 Sambungan selang
5 Kondisi kabinet
6 Isi kabinet Hydrant

1 Control valve
2 Pressure Gauge
3 Perpipaan
Nurse Station (R. Rawat VIP)
4 Sambungan selang
5 Kondisi kabinet
6 Isi kabinet Hydrant

1 Control valve
2 Pressure Gauge
3 Perpipaan
4 Sambungan selang
5 Kondisi kabinet
6 Isi kabinet Hydrant
Aula Besar
 Aula Besar
1 Control valve
2 Pressure Gauge
3 Perpipaan
4 Sambungan selang
5 Kondisi kabinet
6 Isi kabinet Hydrant
ARI Paraf
K3RS
SEP OKT NOV DES BULAN: JAN FEB
KONDISI
Lantai Gedung No Ceklist Item
Baik Rusak
√ 1 Control valve
√ 2 Pressure Gauge
√ 3 Perpipaan
√ 4 Sambungan selang
√ 5 Kondisi kabinet
√ 6 Isi kabinet Hydrant
2
√ 1 Control valve
√ 2 Pressure Gauge
√ 3 Perpipaan
√ 4 Sambungan selang
√ 5 Kondisi kabinet
√ 6 Isi kabinet Hydrant
1
√ 1 Control valve
√ 2 Pressure Gauge
√ 3 Perpipaan
√ 4 Sambungan selang
√ 5 Kondisi kabinet
√ 6 Isi kabinet Hydrant
1
√ 1 Control valve
√ 2 Pressure Gauge
√ 3 Perpipaan
√ 4 Sambungan selang
√ 5 Kondisi kabinet
√ 6 Isi kabinet Hydrant

ARI Paraf
K3RS
SEP OKT NOV DES BULAN: JAN FEB
KONDISI
Lantai Gedung No Ceklist Item
Baik Rusak
 √ 1 Control valve
√ 2 Pressure Gauge
√ 3 Perpipaan
1
√ 4 Sambungan selang
√ 5 Kondisi kabinet
√ 6 Isi kabinet Hydrant

√ 1 Control valve
√ 2 Pressure Gauge
√ 3 Perpipaan
5 2
√ 4 Sambungan selang
√ 5 Kondisi kabinet
√ 6 Isi kabinet Hydrant

√ 1 Control valve
√ 2 Pressure Gauge
√ 3 Perpipaan
2
√ 4 Sambungan selang
√ 5 Kondisi kabinet
√ 6 Isi kabinet Hydrant

ARI Paraf
K3RS
SEP OKT NOV DES BULAN: JAN FEB
KONDISI
Lantai Gedung No Ceklist Item
Baik Rusak
√ 1 Control valve
√ 2 Pressure Gauge
√ 3 Perpipaan
√ 4 Sambungan selang
√ 5 Kondisi kabinet
√ 6 Isi kabinet Hydrant
1
√ 1 Control valve
√ 2 Pressure Gauge
 1

√ 3 Perpipaan
√ 4 Sambungan selang
√ 5 Kondisi kabinet
√ 6 Isi kabinet Hydrant
4
√ 1 Control valve
√ 2 Pressure Gauge
√ 3 Perpipaan
√ 4 Sambungan selang
√ 5 Kondisi kabinet
√ 6 Isi kabinet Hydrant
2
√ 1 Control valve
√ 2 Pressure Gauge
√ 3 Perpipaan
√ 4 Sambungan selang
√ 5 Kondisi kabinet
√ 6 Isi kabinet Hydrant

1 Control valve
2 Pressure Gauge
ARI Paraf
K3RS 3 Perpipaan
SEP OKT NOV DES 4 Sambungan selang
KONDISI 5 Kondisi kabinet
Lantai Gedung
Baik Rusak 6 Isi kabinet Hydrant
√
√ 1 Control valve
√ 2 Pressure Gauge
√ 3 Perpipaan
√ 4 Sambungan selang
√ 5 Kondisi kabinet
6 Isi kabinet Hydrant
√
√ 1 Control valve
√ 2 Pressure Gauge
1
√ 3 Perpipaan
√ 4 Sambungan selang
√ 5 Kondisi kabinet
6 Isi kabinet Hydrant
√
√
√
√
 √ BULAN: JAN FEB
√
No Ceklist Item

√ 1 Control valve
√ 2 Pressure Gauge
√ 3 Perpipaan
2
√ 4 Sambungan selang
√ 5 Kondisi kabinet
√ 6 Isi kabinet Hydrant

√ 1 Control valve
√ 2 Pressure Gauge
√ 3 Perpipaan
√ 4 Sambungan selang
√ 5 Kondisi kabinet
√ 6 Isi kabinet Hydrant
3
√ 1 Control valve
√ 2 Pressure Gauge
√ 3 Perpipaan
√ 4 Sambungan selang
√ 5 Kondisi kabinet
√ 6 Isi kabinet Hydrant

√ 1 Control valve
√ 2 Pressure Gauge
√ 3 Perpipaan
√ 4 Sambungan selang
√ 5 Kondisi kabinet
√ 6 Isi kabinet Hydrant
4
√ 1 Control valve
√ 2 Pressure Gauge
√ 3 Perpipaan
√ 4 Sambungan selang
√ 5 Kondisi kabinet
√ 6 Isi kabinet Hydrant
3
√ 1 Control valve
√ 2 Pressure Gauge
√ 3 Perpipaan
√ 4 Sambungan selang
√ 5 Kondisi kabinet

5
 √ 6 Isi kabinet Hydrant
5
√
√
√
√ BULAN: JAN FEB
√
No Ceklist Item
√
1 Control valve
√ 2 Pressure Gauge
√ 3 Perpipaan
√ 4 Sambungan selang
√ 5 Kondisi kabinet
√ 6 Isi kabinet Hydrant
√
6 1 Control valve
√ 2 Pressure Gauge
√ 3 Perpipaan
√ 4 Sambungan selang
√ 5 Kondisi kabinet
√ 6 Isi kabinet Hydrant
√
1 Control valve
√ 2 Pressure Gauge
√ 3 Perpipaan
√ 4 Sambungan selang
√ 5 Kondisi kabinet
√ 6 Isi kabinet Hydrant
√
7 1 Control valve
√ 2 Pressure Gauge
√ 3 Perpipaan
√ 4 Sambungan selang
√ 5 Kondisi kabinet
√ 6 Isi kabinet Hydrant
√

√
√
√
√
√
√
8
8
√
√
√
√
√
√
 INSPEKSI HYDRANT SETIAP 30 HARI

MAR APR MEI JUN JUL AGS SEP OKT NOV DES

Ceklist Item Lokasi Hydrant Lantai Gedung

alve

n
Isolasi paru
an selang

1
alve
Gauge
n
Belakang isolasi paru
an selang
abinet
t Hydrant
3
alve
Gauge
n
Klinik anak
an selang
abinet
t Hydrant
2
alve
Gauge
n
Connecting bedah umum
an selang
abinet
t Hydrant

INSPEKSI HYDRANT SETIAP 30 HARI

MAR APR MEI JUN JUL AGS SEP OKT NOV DES

Ceklist Item Lokasi Hydrant Lantai Gedung

alve

n
Poli DM
an selang

2
alve
Gauge
n
Depan VK 3 2
an selang
abinet
t Hydrant

alve
Gauge
n
ICU covid 1
an selang
abinet
t Hydrant

INSPEKSI HYDRANT SETIAP 30 HARI

MAR APR MEI JUN JUL AGS SEP OKT NOV DES

Ceklist Item Lokasi Hydrant Lantai Gedung

alve

n
Lobby
an selang

alve
Gauge

Depan UGD (Lama)

n
Depan UGD (Lama)
an selang
abinet
t Hydrant

alve
Gauge
n
Samping WTP
an selang
abinet
t Hydrant

alve
Gauge
n Luar
Depan Masjid 1
an selang Gedung
abinet
t Hydrant

alve
Gauge
n
an selang
abinet
t Hydrant

alve
Gauge
n
Parkir Mobil
an selang
abinet
t Hydrant

alve
Gauge
n
an selang
abinet
t Hydrant

INSPEKSI HYDRANT SETIAP 30 HARI

 MAR APR MEI JUN JUL AGS SEP OKT NOV DES

Ceklist Item Lokasi Hydrant Lantai Gedung

alve

n
an selang

alve
Gauge
n
an selang
abinet
t Hydrant

alve
Gauge
n
an selang
abinet
t Hydrant
Luar
Parkir Gedung 3&4 1
Gedung
alve
Gauge
n
an selang
abinet
t Hydrant

alve
Gauge
n
an selang
abinet
t Hydrant

alve
Gauge
n
an selang
abinet
t Hydrant

INSPEKSI HYDRANT SETIAP 30 HARI

MAR APR MEI JUN JUL AGS SEP OKT NOV DES

Ceklist Item Lokasi Hydrant Lantai Gedung

alve

n
Selasar Linen 1
an selang

alve
Gauge
n
Depan R. Control 2
an selang
abinet
t Hydrant
4 (Linen)
alve
Gauge
n
R. Farmasi 3
an selang
abinet
t Hydrant

alve
Gauge
n
Depan Gudang Galon Gizi 4
an selang
abinet
t Hydrant
 Paraf
K3RS

KONDISI
Baik Rusak
√
√
√
√
√
√

√
√
√
√
√
√

√
√
√
√
√
√

√
√
√
√
√
√

Paraf
K3RS

KONDISI
Baik Rusak
√
√
√
√
√
√

√
√
√
√
√
√

√
√
√
√
√
√

Paraf
K3RS

KONDISI
Baik Rusak
√
√
√
√
√
√

√
√
√
√
√
√

√
√
√
√
√
√

√
√
√
√
√
√

√
√
√
√
√
√

√
√
√
√
√
√

√
√
√
√
√
√

Paraf
K3RS
 Paraf
K3RS

KONDISI
Baik Rusak
√
√
√
√
√
√

√
√
√
√
√
√

√
√
√
√
√
√

√
√
√
√
√
√

√
√
√
√
√
√

√
√
√
√
√
√

Paraf
K3RS

KONDISI
Baik Rusak
√
√
√
√
√
√

√
√
√
√
√
√

√
√
√
√
√
√

√
√
√
√
√
√
 INSPEKSI HYDRANT SETIAP 30 HARI

BULAN: JAN FEB MAR APR MEI JUN JUL AGS

No Ceklist Item Lokasi Hydrant

1 Control valve
2 Pressure Gauge
3 Perpipaan
Klinik orthopedi
4 Sambungan selang
5 Kondisi kabinet
6 Isi kabinet Hydrant

1 Control valve
2 Pressure Gauge
3 Perpipaan
Depan pendaftaran BPJS
4 Sambungan selang
5 Kondisi kabinet
6 Isi kabinet Hydrant

1 Control valve
2 Pressure Gauge
3 Perpipaan
Depan toilet belakang IGD lama
4 Sambungan selang
5 Kondisi kabinet
6 Isi kabinet Hydrant

1 Control valve
2 Pressure Gauge
3 Perpipaan IGD lama (Kondisi terhalang baby
4 Sambungan selang incubator)
5 Kondisi kabinet
6 Isi kabinet Hydrant

INSPEKSI HYDRANT SETIAP 30 HARI

BULAN: JAN FEB MAR APR MEI JUN JUL AGS

No Ceklist Item Lokasi Hydrant

 1 Control valve
2 Pressure Gauge
3 Perpipaan
Depan poliklinik rehab medik
4 Sambungan selang
5 Kondisi kabinet
6 Isi kabinet Hydrant

1 Control valve
2 Pressure Gauge
3 Perpipaan
Aula komite medik
4 Sambungan selang
5 Kondisi kabinet
6 Isi kabinet Hydrant

1 Control valve
2 Pressure Gauge
3 Perpipaan
Rekam medik
4 Sambungan selang
5 Kondisi kabinet
6 Isi kabinet Hydrant

INSPEKSI HYDRANT SETIAP 30 HARI

BULAN: JAN FEB MAR APR MEI JUN JUL AGS

No Ceklist Item Lokasi Hydrant

1 Control valve
2 Pressure Gauge
3 Perpipaan
Wing covid
4 Sambungan selang
5 Kondisi kabinet
6 Isi kabinet Hydrant

1 Control valve
2 Pressure Gauge

Belakang wing covid

 3 Perpipaan
Belakang wing covid
4 Sambungan selang
5 Kondisi kabinet
6 Isi kabinet Hydrant

1 Control valve
2 Pressure Gauge
3 Perpipaan
Poli B20
4 Sambungan selang
5 Kondisi kabinet
6 Isi kabinet Hydrant

1 Control valve
2 Pressure Gauge
3 Perpipaan
Ruang RO
4 Sambungan selang
5 Kondisi kabinet
6 Isi kabinet Hydrant

INSPEKSI HYDRANT SETIAP 30 HARI

BULAN: JAN FEB MAR APR MEI JUN JUL AGS

No Ceklist Item Lokasi Hydrant

1 Control valve
2 Pressure Gauge
3 Perpipaan
IGD Baru
4 Sambungan selang
5 Kondisi kabinet
6 Isi kabinet Hydrant

1 Control valve
2 Pressure Gauge
3 Perpipaan
R. Radiologi
4 Sambungan selang
5 Kondisi kabinet
6 Isi kabinet Hydrant

1 Control valve
2 Pressure Gauge
3 Perpipaan
Laboratorium
4 Sambungan selang
 Laboratorium

5 Kondisi kabinet
6 Isi kabinet Hydrant

1 Control valve
2 Pressure Gauge
3 Perpipaan
PICU
4 Sambungan selang
5 Kondisi kabinet
6 Isi kabinet Hydrant

1 Control valve
2 Pressure Gauge
3 Perpipaan
Dalam R. OK
4 Sambungan selang
5 Kondisi kabinet
6 Isi kabinet Hydrant

1 Control valve
2 Pressure Gauge
3 Perpipaan
Dalam R. CSSD
4 Sambungan selang
5 Kondisi kabinet
6 Isi kabinet Hydrant

1 Control valve
2 Pressure Gauge
3 Perpipaan
R. Aula Rapat
4 Sambungan selang
5 Kondisi kabinet
6 Isi kabinet Hydrant

1 Control valve
2 Pressure Gauge
3 Perpipaan
R. Management
4 Sambungan selang
5 Kondisi kabinet
6 Isi kabinet Hydrant

1 Control valve
2 Pressure Gauge
3 Perpipaan
Nurse Station
4 Sambungan selang
5 Kondisi kabinet
 Nurse Station

6 Isi kabinet Hydrant

1 Control valve
2 Pressure Gauge
3 Perpipaan
Nurse Station
4 Sambungan selang
5 Kondisi kabinet
6 Isi kabinet Hydrant

1 Control valve
2 Pressure Gauge
3 Perpipaan
Nurse Station
4 Sambungan selang
5 Kondisi kabinet
6 Isi kabinet Hydrant

1 Control valve
2 Pressure Gauge
3 Perpipaan
Nurse Station
4 Sambungan selang
5 Kondisi kabinet
6 Isi kabinet Hydrant

1 Control valve
2 Pressure Gauge
3 Perpipaan
Nurse Station (R. Rawat VIP)
4 Sambungan selang
5 Kondisi kabinet
6 Isi kabinet Hydrant

1 Control valve
2 Pressure Gauge
3 Perpipaan
Nurse Station (R. Rawat VIP)
4 Sambungan selang
5 Kondisi kabinet
6 Isi kabinet Hydrant

1 Control valve
2 Pressure Gauge
3 Perpipaan
4 Sambungan selang
5 Kondisi kabinet
6 Isi kabinet Hydrant
Aula Besar
 Aula Besar
1 Control valve
2 Pressure Gauge
3 Perpipaan
4 Sambungan selang
5 Kondisi kabinet
6 Isi kabinet Hydrant
ARI Paraf
K3RS
SEP OKT NOV DES BULAN: JAN FEB
KONDISI
Lantai Gedung No Ceklist Item
Baik Rusak
√ 1 Control valve
√ 2 Pressure Gauge
√ 3 Perpipaan
√ 4 Sambungan selang
√ 5 Kondisi kabinet
√ 6 Isi kabinet Hydrant
2
√ 1 Control valve
√ 2 Pressure Gauge
√ 3 Perpipaan
√ 4 Sambungan selang
√ 5 Kondisi kabinet
√ 6 Isi kabinet Hydrant
1
√ 1 Control valve
√ 2 Pressure Gauge
√ 3 Perpipaan
√ 4 Sambungan selang
√ 5 Kondisi kabinet
√ 6 Isi kabinet Hydrant
1
√ 1 Control valve
√ 2 Pressure Gauge
√ 3 Perpipaan
√ 4 Sambungan selang
√ 5 Kondisi kabinet
√ 6 Isi kabinet Hydrant

ARI Paraf
K3RS
SEP OKT NOV DES BULAN: JAN FEB
KONDISI
Lantai Gedung No Ceklist Item
Baik Rusak
 √ 1 Control valve
√ 2 Pressure Gauge
√ 3 Perpipaan
1
√ 4 Sambungan selang
√ 5 Kondisi kabinet
√ 6 Isi kabinet Hydrant

√ 1 Control valve
√ 2 Pressure Gauge
√ 3 Perpipaan
5 2
√ 4 Sambungan selang
√ 5 Kondisi kabinet
√ 6 Isi kabinet Hydrant

√ 1 Control valve
√ 2 Pressure Gauge
√ 3 Perpipaan
2
√ 4 Sambungan selang
√ 5 Kondisi kabinet
√ 6 Isi kabinet Hydrant

ARI Paraf
K3RS
SEP OKT NOV DES BULAN: JAN FEB
KONDISI
Lantai Gedung No Ceklist Item
Baik Rusak
√ 1 Control valve
√ 2 Pressure Gauge
√ 3 Perpipaan
√ 4 Sambungan selang
√ 5 Kondisi kabinet
√ 6 Isi kabinet Hydrant
1
√ 1 Control valve
√ 2 Pressure Gauge
 1

√ 3 Perpipaan
√ 4 Sambungan selang
√ 5 Kondisi kabinet
√ 6 Isi kabinet Hydrant
4
√ 1 Control valve
√ 2 Pressure Gauge
√ 3 Perpipaan
√ 4 Sambungan selang
√ 5 Kondisi kabinet
√ 6 Isi kabinet Hydrant
2
√ 1 Control valve
√ 2 Pressure Gauge
√ 3 Perpipaan
√ 4 Sambungan selang
√ 5 Kondisi kabinet
√ 6 Isi kabinet Hydrant

1 Control valve
2 Pressure Gauge
ARI Paraf
K3RS 3 Perpipaan
SEP OKT NOV DES 4 Sambungan selang
KONDISI 5 Kondisi kabinet
Lantai Gedung
Baik Rusak 6 Isi kabinet Hydrant
√
√ 1 Control valve
√ 2 Pressure Gauge
√ 3 Perpipaan
√ 4 Sambungan selang
√ 5 Kondisi kabinet
6 Isi kabinet Hydrant
√
√ 1 Control valve
√ 2 Pressure Gauge
1
√ 3 Perpipaan
√ 4 Sambungan selang
√ 5 Kondisi kabinet
6 Isi kabinet Hydrant
√
√
√
√
 √ BULAN: JAN FEB
√
No Ceklist Item

√ 1 Control valve
√ 2 Pressure Gauge
√ 3 Perpipaan
2
√ 4 Sambungan selang
√ 5 Kondisi kabinet
√ 6 Isi kabinet Hydrant

√ 1 Control valve
√ 2 Pressure Gauge
√ 3 Perpipaan
√ 4 Sambungan selang
√ 5 Kondisi kabinet
√ 6 Isi kabinet Hydrant
3
√ 1 Control valve
√ 2 Pressure Gauge
√ 3 Perpipaan
√ 4 Sambungan selang
√ 5 Kondisi kabinet
√ 6 Isi kabinet Hydrant

√ 1 Control valve
√ 2 Pressure Gauge
√ 3 Perpipaan
√ 4 Sambungan selang
√ 5 Kondisi kabinet
√ 6 Isi kabinet Hydrant
4
√ 1 Control valve
√ 2 Pressure Gauge
√ 3 Perpipaan
√ 4 Sambungan selang
√ 5 Kondisi kabinet
√ 6 Isi kabinet Hydrant
3
√ 1 Control valve
√ 2 Pressure Gauge
√ 3 Perpipaan
√ 4 Sambungan selang
√ 5 Kondisi kabinet

5
 √ 6 Isi kabinet Hydrant
5
√
√
√
√ BULAN: JAN FEB
√
No Ceklist Item
√
1 Control valve
√ 2 Pressure Gauge
√ 3 Perpipaan
√ 4 Sambungan selang
√ 5 Kondisi kabinet
√ 6 Isi kabinet Hydrant
√
6 1 Control valve
√ 2 Pressure Gauge
√ 3 Perpipaan
√ 4 Sambungan selang
√ 5 Kondisi kabinet
√ 6 Isi kabinet Hydrant
√
1 Control valve
√ 2 Pressure Gauge
√ 3 Perpipaan
√ 4 Sambungan selang
√ 5 Kondisi kabinet
√ 6 Isi kabinet Hydrant
√
7 1 Control valve
√ 2 Pressure Gauge
√ 3 Perpipaan
√ 4 Sambungan selang
√ 5 Kondisi kabinet
√ 6 Isi kabinet Hydrant
√

√
√
√
√
√
√
8
8
√
√
√
√
√
√
 INSPEKSI HYDRANT SETIAP 30 HARI

MAR APR MEI JUN JUL AGS SEP OKT NOV DES

Ceklist Item Lokasi Hydrant Lantai Gedung

alve

n
Isolasi paru
an selang

1
alve
Gauge
n
Belakang isolasi paru
an selang
abinet
t Hydrant
3
alve
Gauge
n
Klinik anak
an selang
abinet
t Hydrant
2
alve
Gauge
n
Connecting bedah umum
an selang
abinet
t Hydrant

INSPEKSI HYDRANT SETIAP 30 HARI

MAR APR MEI JUN JUL AGS SEP OKT NOV DES

Ceklist Item Lokasi Hydrant Lantai Gedung

alve

n
Poli DM
an selang

2
alve
Gauge
n
Depan VK 3 2
an selang
abinet
t Hydrant

alve
Gauge
n
ICU covid 1
an selang
abinet
t Hydrant

INSPEKSI HYDRANT SETIAP 30 HARI

MAR APR MEI JUN JUL AGS SEP OKT NOV DES

Ceklist Item Lokasi Hydrant Lantai Gedung

alve

n
Lobby
an selang

alve
Gauge

Depan UGD (Lama)

n
Depan UGD (Lama)
an selang
abinet
t Hydrant

alve
Gauge
n
Samping WTP
an selang
abinet
t Hydrant

alve
Gauge
n Luar
Depan Masjid 1
an selang Gedung
abinet
t Hydrant

alve
Gauge
n
an selang
abinet
t Hydrant

alve
Gauge
n
Parkir Mobil
an selang
abinet
t Hydrant

alve
Gauge
n
an selang
abinet
t Hydrant

INSPEKSI HYDRANT SETIAP 30 HARI

 MAR APR MEI JUN JUL AGS SEP OKT NOV DES

Ceklist Item Lokasi Hydrant Lantai Gedung

alve

n
an selang

alve
Gauge
n
an selang
abinet
t Hydrant

alve
Gauge
n
an selang
abinet
t Hydrant
Luar
Parkir Gedung 3&4 1
Gedung
alve
Gauge
n
an selang
abinet
t Hydrant

alve
Gauge
n
an selang
abinet
t Hydrant

alve
Gauge
n
an selang
abinet
t Hydrant

INSPEKSI HYDRANT SETIAP 30 HARI

MAR APR MEI JUN JUL AGS SEP OKT NOV DES

Ceklist Item Lokasi Hydrant Lantai Gedung

alve

n
Selasar Linen 1
an selang

alve
Gauge
n
Depan R. Control 2
an selang
abinet
t Hydrant
4 (Linen)
alve
Gauge
n
R. Farmasi 3
an selang
abinet
t Hydrant

alve
Gauge
n
Depan Gudang Galon Gizi 4
an selang
abinet
t Hydrant
 Paraf
K3RS

KONDISI
Baik Rusak
√
√
√
√
√
√

√
√
√
√
√
√

√
√
√
√
√
√

√
√
√
√
√
√

Paraf
K3RS

KONDISI
Baik Rusak
√
√
√
√
√
√

√
√
√
√
√
√

√
√
√
√
√
√

Paraf
K3RS

KONDISI
Baik Rusak
√
√
√
√
√
√

√
√
√
√
√
√

√
√
√
√
√
√

√
√
√
√
√
√

√
√
√
√
√
√

√
√
√
√
√
√

√
√
√
√
√
√

Paraf
K3RS
 Paraf
K3RS

KONDISI
Baik Rusak
√
√
√
√
√
√

√
√
√
√
√
√

√
√
√
√
√
√

√
√
√
√
√
√

√
√
√
√
√
√

√
√
√
√
√
√

Paraf
K3RS

KONDISI
Baik Rusak
√
√
√
√
√
√

√
√
√
√
√
√

√
√
√
√
√
√

√
√
√
√
√
√
 INSPEKSI HYDRANT SETIAP 30 HARI

BULAN: JAN FEB MAR APR MEI JUN JUL AGS

No Ceklist Item Lokasi Hydrant

1 Control valve
2 Pressure Gauge
3 Perpipaan
Klinik orthopedi
4 Sambungan selang
5 Kondisi kabinet
6 Isi kabinet Hydrant

1 Control valve
2 Pressure Gauge
3 Perpipaan
Depan pendaftaran BPJS
4 Sambungan selang
5 Kondisi kabinet
6 Isi kabinet Hydrant

1 Control valve
2 Pressure Gauge
3 Perpipaan
Depan toilet belakang IGD lama
4 Sambungan selang
5 Kondisi kabinet
6 Isi kabinet Hydrant

1 Control valve
2 Pressure Gauge
3 Perpipaan IGD lama (Kondisi terhalang baby
4 Sambungan selang incubator)
5 Kondisi kabinet
6 Isi kabinet Hydrant

INSPEKSI HYDRANT SETIAP 30 HARI

BULAN: JAN FEB MAR APR MEI JUN JUL AGS

No Ceklist Item Lokasi Hydrant

 1 Control valve
2 Pressure Gauge
3 Perpipaan
Depan poliklinik rehab medik
4 Sambungan selang
5 Kondisi kabinet
6 Isi kabinet Hydrant

1 Control valve
2 Pressure Gauge
3 Perpipaan
Aula komite medik
4 Sambungan selang
5 Kondisi kabinet
6 Isi kabinet Hydrant

1 Control valve
2 Pressure Gauge
3 Perpipaan
Rekam medik
4 Sambungan selang
5 Kondisi kabinet
6 Isi kabinet Hydrant

INSPEKSI HYDRANT SETIAP 30 HARI

BULAN: JAN FEB MAR APR MEI JUN JUL AGS

No Ceklist Item Lokasi Hydrant

1 Control valve
2 Pressure Gauge
3 Perpipaan
Wing covid
4 Sambungan selang
5 Kondisi kabinet
6 Isi kabinet Hydrant

1 Control valve
2 Pressure Gauge

Belakang wing covid

 3 Perpipaan
Belakang wing covid
4 Sambungan selang
5 Kondisi kabinet
6 Isi kabinet Hydrant

1 Control valve
2 Pressure Gauge
3 Perpipaan
Poli B20
4 Sambungan selang
5 Kondisi kabinet
6 Isi kabinet Hydrant

1 Control valve
2 Pressure Gauge
3 Perpipaan
Ruang RO
4 Sambungan selang
5 Kondisi kabinet
6 Isi kabinet Hydrant

INSPEKSI HYDRANT SETIAP 30 HARI

BULAN: JAN FEB MAR APR MEI JUN JUL AGS

No Ceklist Item Lokasi Hydrant

1 Control valve
2 Pressure Gauge
3 Perpipaan
IGD Baru
4 Sambungan selang
5 Kondisi kabinet
6 Isi kabinet Hydrant

1 Control valve
2 Pressure Gauge
3 Perpipaan
R. Radiologi
4 Sambungan selang
5 Kondisi kabinet
6 Isi kabinet Hydrant

1 Control valve
2 Pressure Gauge
3 Perpipaan
Laboratorium
4 Sambungan selang
 Laboratorium

5 Kondisi kabinet
6 Isi kabinet Hydrant

1 Control valve
2 Pressure Gauge
3 Perpipaan
PICU
4 Sambungan selang
5 Kondisi kabinet
6 Isi kabinet Hydrant

1 Control valve
2 Pressure Gauge
3 Perpipaan
Dalam R. OK
4 Sambungan selang
5 Kondisi kabinet
6 Isi kabinet Hydrant

1 Control valve
2 Pressure Gauge
3 Perpipaan
Dalam R. CSSD
4 Sambungan selang
5 Kondisi kabinet
6 Isi kabinet Hydrant

1 Control valve
2 Pressure Gauge
3 Perpipaan
R. Aula Rapat
4 Sambungan selang
5 Kondisi kabinet
6 Isi kabinet Hydrant

1 Control valve
2 Pressure Gauge
3 Perpipaan
R. Management
4 Sambungan selang
5 Kondisi kabinet
6 Isi kabinet Hydrant

1 Control valve
2 Pressure Gauge
3 Perpipaan
Nurse Station
4 Sambungan selang
5 Kondisi kabinet
 Nurse Station

6 Isi kabinet Hydrant

1 Control valve
2 Pressure Gauge
3 Perpipaan
Nurse Station
4 Sambungan selang
5 Kondisi kabinet
6 Isi kabinet Hydrant

1 Control valve
2 Pressure Gauge
3 Perpipaan
Nurse Station
4 Sambungan selang
5 Kondisi kabinet
6 Isi kabinet Hydrant

1 Control valve
2 Pressure Gauge
3 Perpipaan
Nurse Station
4 Sambungan selang
5 Kondisi kabinet
6 Isi kabinet Hydrant

1 Control valve
2 Pressure Gauge
3 Perpipaan
Nurse Station (R. Rawat VIP)
4 Sambungan selang
5 Kondisi kabinet
6 Isi kabinet Hydrant

1 Control valve
2 Pressure Gauge
3 Perpipaan
Nurse Station (R. Rawat VIP)
4 Sambungan selang
5 Kondisi kabinet
6 Isi kabinet Hydrant

1 Control valve
2 Pressure Gauge
3 Perpipaan
4 Sambungan selang
5 Kondisi kabinet
6 Isi kabinet Hydrant
Aula Besar
 Aula Besar
1 Control valve
2 Pressure Gauge
3 Perpipaan
4 Sambungan selang
5 Kondisi kabinet
6 Isi kabinet Hydrant
ARI Paraf
K3RS
SEP OKT NOV DES BULAN: JAN FEB
KONDISI
Lantai Gedung No Ceklist Item
Baik Rusak
√ 1 Control valve
√ 2 Pressure Gauge
√ 3 Perpipaan
√ 4 Sambungan selang
√ 5 Kondisi kabinet
√ 6 Isi kabinet Hydrant
2
√ 1 Control valve
√ 2 Pressure Gauge
√ 3 Perpipaan
√ 4 Sambungan selang
√ 5 Kondisi kabinet
√ 6 Isi kabinet Hydrant
1
√ 1 Control valve
√ 2 Pressure Gauge
√ 3 Perpipaan
√ 4 Sambungan selang
√ 5 Kondisi kabinet
√ 6 Isi kabinet Hydrant
1
√ 1 Control valve
√ 2 Pressure Gauge
√ 3 Perpipaan
√ 4 Sambungan selang
√ 5 Kondisi kabinet
√ 6 Isi kabinet Hydrant

ARI Paraf
K3RS
SEP OKT NOV DES BULAN: JAN FEB
KONDISI
Lantai Gedung No Ceklist Item
Baik Rusak
 √ 1 Control valve
√ 2 Pressure Gauge
√ 3 Perpipaan
1
√ 4 Sambungan selang
√ 5 Kondisi kabinet
√ 6 Isi kabinet Hydrant

√ 1 Control valve
√ 2 Pressure Gauge
√ 3 Perpipaan
5 2
√ 4 Sambungan selang
√ 5 Kondisi kabinet
√ 6 Isi kabinet Hydrant

√ 1 Control valve
√ 2 Pressure Gauge
√ 3 Perpipaan
2
√ 4 Sambungan selang
√ 5 Kondisi kabinet
√ 6 Isi kabinet Hydrant

ARI Paraf
K3RS
SEP OKT NOV DES BULAN: JAN FEB
KONDISI
Lantai Gedung No Ceklist Item
Baik Rusak
√ 1 Control valve
√ 2 Pressure Gauge
√ 3 Perpipaan
√ 4 Sambungan selang
√ 5 Kondisi kabinet
√ 6 Isi kabinet Hydrant
1
√ 1 Control valve
√ 2 Pressure Gauge
 1

√ 3 Perpipaan
√ 4 Sambungan selang
√ 5 Kondisi kabinet
√ 6 Isi kabinet Hydrant
4
√ 1 Control valve
√ 2 Pressure Gauge
√ 3 Perpipaan
√ 4 Sambungan selang
√ 5 Kondisi kabinet
√ 6 Isi kabinet Hydrant
2
√ 1 Control valve
√ 2 Pressure Gauge
√ 3 Perpipaan
√ 4 Sambungan selang
√ 5 Kondisi kabinet
√ 6 Isi kabinet Hydrant

1 Control valve
2 Pressure Gauge
ARI Paraf
K3RS 3 Perpipaan
SEP OKT NOV DES 4 Sambungan selang
KONDISI 5 Kondisi kabinet
Lantai Gedung
Baik Rusak 6 Isi kabinet Hydrant
√
√ 1 Control valve
√ 2 Pressure Gauge
√ 3 Perpipaan
√ 4 Sambungan selang
√ 5 Kondisi kabinet
6 Isi kabinet Hydrant
√
√ 1 Control valve
√ 2 Pressure Gauge
1
√ 3 Perpipaan
√ 4 Sambungan selang
√ 5 Kondisi kabinet
6 Isi kabinet Hydrant
√
√
√
√
 √ BULAN: JAN FEB
√
No Ceklist Item

√ 1 Control valve
√ 2 Pressure Gauge
√ 3 Perpipaan
2
√ 4 Sambungan selang
√ 5 Kondisi kabinet
√ 6 Isi kabinet Hydrant

√ 1 Control valve
√ 2 Pressure Gauge
√ 3 Perpipaan
√ 4 Sambungan selang
√ 5 Kondisi kabinet
√ 6 Isi kabinet Hydrant
3
√ 1 Control valve
√ 2 Pressure Gauge
√ 3 Perpipaan
√ 4 Sambungan selang
√ 5 Kondisi kabinet
√ 6 Isi kabinet Hydrant

√ 1 Control valve
√ 2 Pressure Gauge
√ 3 Perpipaan
√ 4 Sambungan selang
√ 5 Kondisi kabinet
√ 6 Isi kabinet Hydrant
4
√ 1 Control valve
√ 2 Pressure Gauge
√ 3 Perpipaan
√ 4 Sambungan selang
√ 5 Kondisi kabinet
√ 6 Isi kabinet Hydrant
3
√ 1 Control valve
√ 2 Pressure Gauge
√ 3 Perpipaan
√ 4 Sambungan selang
√ 5 Kondisi kabinet

5
 √ 6 Isi kabinet Hydrant
5
√
√
√
√ BULAN: JAN FEB
√
No Ceklist Item
√
1 Control valve
√ 2 Pressure Gauge
√ 3 Perpipaan
√ 4 Sambungan selang
√ 5 Kondisi kabinet
√ 6 Isi kabinet Hydrant
√
6 1 Control valve
√ 2 Pressure Gauge
√ 3 Perpipaan
√ 4 Sambungan selang
√ 5 Kondisi kabinet
√ 6 Isi kabinet Hydrant
√
1 Control valve
√ 2 Pressure Gauge
√ 3 Perpipaan
√ 4 Sambungan selang
√ 5 Kondisi kabinet
√ 6 Isi kabinet Hydrant
√
7 1 Control valve
√ 2 Pressure Gauge
√ 3 Perpipaan
√ 4 Sambungan selang
√ 5 Kondisi kabinet
√ 6 Isi kabinet Hydrant
√

√
√
√
√
√
√
8
8
√
√
√
√
√
√
 INSPEKSI HYDRANT SETIAP 30 HARI

MAR APR MEI JUN JUL AGS SEP OKT NOV DES

Ceklist Item Lokasi Hydrant Lantai Gedung

alve

n
Isolasi paru
an selang

1
alve
Gauge
n
Belakang isolasi paru
an selang
abinet
t Hydrant
3
alve
Gauge
n
Klinik anak
an selang
abinet
t Hydrant
2
alve
Gauge
n
Connecting bedah umum
an selang
abinet
t Hydrant

INSPEKSI HYDRANT SETIAP 30 HARI

MAR APR MEI JUN JUL AGS SEP OKT NOV DES

Ceklist Item Lokasi Hydrant Lantai Gedung

alve

n
Poli DM
an selang

2
alve
Gauge
n
Depan VK 3 2
an selang
abinet
t Hydrant

alve
Gauge
n
ICU covid 1
an selang
abinet
t Hydrant

INSPEKSI HYDRANT SETIAP 30 HARI

MAR APR MEI JUN JUL AGS SEP OKT NOV DES

Ceklist Item Lokasi Hydrant Lantai Gedung

alve

n
Lobby
an selang

alve
Gauge

Depan UGD (Lama)

n
Depan UGD (Lama)
an selang
abinet
t Hydrant

alve
Gauge
n
Samping WTP
an selang
abinet
t Hydrant

alve
Gauge
n Luar
Depan Masjid 1
an selang Gedung
abinet
t Hydrant

alve
Gauge
n
an selang
abinet
t Hydrant

alve
Gauge
n
Parkir Mobil
an selang
abinet
t Hydrant

alve
Gauge
n
an selang
abinet
t Hydrant

INSPEKSI HYDRANT SETIAP 30 HARI

 MAR APR MEI JUN JUL AGS SEP OKT NOV DES

Ceklist Item Lokasi Hydrant Lantai Gedung

alve

n
an selang

alve
Gauge
n
an selang
abinet
t Hydrant

alve
Gauge
n
an selang
abinet
t Hydrant
Luar
Parkir Gedung 3&4 1
Gedung
alve
Gauge
n
an selang
abinet
t Hydrant

alve
Gauge
n
an selang
abinet
t Hydrant

alve
Gauge
n
an selang
abinet
t Hydrant

INSPEKSI HYDRANT SETIAP 30 HARI

MAR APR MEI JUN JUL AGS SEP OKT NOV DES

Ceklist Item Lokasi Hydrant Lantai Gedung

alve

n
Selasar Linen 1
an selang

alve
Gauge
n
Depan R. Control 2
an selang
abinet
t Hydrant
4 (Linen)
alve
Gauge
n
R. Farmasi 3
an selang
abinet
t Hydrant

alve
Gauge
n
Depan Gudang Galon Gizi 4
an selang
abinet
t Hydrant
 Paraf
K3RS

KONDISI
Baik Rusak
√
√
√
√
√
√

√
√
√
√
√
√

√
√
√
√
√
√

√
√
√
√
√
√

Paraf
K3RS

KONDISI
Baik Rusak
√
√
√
√
√
√

√
√
√
√
√
√

√
√
√
√
√
√

Paraf
K3RS

KONDISI
Baik Rusak
√
√
√
√
√
√

√
√
√
√
√
√

√
√
√
√
√
√

√
√
√
√
√
√

√
√
√
√
√
√

√
√
√
√
√
√

√
√
√
√
√
√

Paraf
K3RS
 Paraf
K3RS

KONDISI
Baik Rusak
√
√
√
√
√
√

√
√
√
√
√
√

√
√
√
√
√
√

√
√
√
√
√
√

√
√
√
√
√
√

√
√
√
√
√
√

Paraf
K3RS

KONDISI
Baik Rusak
√
√
√
√
√
√

√
√
√
√
√
√

√
√
√
√
√
√

√
√
√
√
√
√
 INSPEKSI HYDRANT SETIAP 30 HARI

BULAN: JAN FEB MAR APR MEI JUN JUL AGS

No Ceklist Item Lokasi Hydrant

1 Control valve
2 Pressure Gauge
3 Perpipaan
Klinik orthopedi
4 Sambungan selang
5 Kondisi kabinet
6 Isi kabinet Hydrant

1 Control valve
2 Pressure Gauge
3 Perpipaan
Depan pendaftaran BPJS
4 Sambungan selang
5 Kondisi kabinet
6 Isi kabinet Hydrant

1 Control valve
2 Pressure Gauge
3 Perpipaan
Depan toilet belakang IGD lama
4 Sambungan selang
5 Kondisi kabinet
6 Isi kabinet Hydrant

1 Control valve
2 Pressure Gauge
3 Perpipaan IGD lama (Kondisi terhalang baby
4 Sambungan selang incubator)
5 Kondisi kabinet
6 Isi kabinet Hydrant

INSPEKSI HYDRANT SETIAP 30 HARI

BULAN: JAN FEB MAR APR MEI JUN JUL AGS

No Ceklist Item Lokasi Hydrant

 1 Control valve
2 Pressure Gauge
3 Perpipaan
Depan poliklinik rehab medik
4 Sambungan selang
5 Kondisi kabinet
6 Isi kabinet Hydrant

1 Control valve
2 Pressure Gauge
3 Perpipaan
Aula komite medik
4 Sambungan selang
5 Kondisi kabinet
6 Isi kabinet Hydrant

1 Control valve
2 Pressure Gauge
3 Perpipaan
Rekam medik
4 Sambungan selang
5 Kondisi kabinet
6 Isi kabinet Hydrant

INSPEKSI HYDRANT SETIAP 30 HARI

BULAN: JAN FEB MAR APR MEI JUN JUL AGS

No Ceklist Item Lokasi Hydrant

1 Control valve
2 Pressure Gauge
3 Perpipaan
Wing covid
4 Sambungan selang
5 Kondisi kabinet
6 Isi kabinet Hydrant

1 Control valve
2 Pressure Gauge

Belakang wing covid

 3 Perpipaan
Belakang wing covid
4 Sambungan selang
5 Kondisi kabinet
6 Isi kabinet Hydrant

1 Control valve
2 Pressure Gauge
3 Perpipaan
Poli B20
4 Sambungan selang
5 Kondisi kabinet
6 Isi kabinet Hydrant

1 Control valve
2 Pressure Gauge
3 Perpipaan
Ruang RO
4 Sambungan selang
5 Kondisi kabinet
6 Isi kabinet Hydrant

INSPEKSI HYDRANT SETIAP 30 HARI

BULAN: JAN FEB MAR APR MEI JUN JUL AGS

No Ceklist Item Lokasi Hydrant

1 Control valve
2 Pressure Gauge
3 Perpipaan
IGD Baru
4 Sambungan selang
5 Kondisi kabinet
6 Isi kabinet Hydrant

1 Control valve
2 Pressure Gauge
3 Perpipaan
R. Radiologi
4 Sambungan selang
5 Kondisi kabinet
6 Isi kabinet Hydrant

1 Control valve
2 Pressure Gauge
3 Perpipaan
Laboratorium
4 Sambungan selang
 Laboratorium

5 Kondisi kabinet
6 Isi kabinet Hydrant

1 Control valve
2 Pressure Gauge
3 Perpipaan
PICU
4 Sambungan selang
5 Kondisi kabinet
6 Isi kabinet Hydrant

1 Control valve
2 Pressure Gauge
3 Perpipaan
Dalam R. OK
4 Sambungan selang
5 Kondisi kabinet
6 Isi kabinet Hydrant

1 Control valve
2 Pressure Gauge
3 Perpipaan
Dalam R. CSSD
4 Sambungan selang
5 Kondisi kabinet
6 Isi kabinet Hydrant

1 Control valve
2 Pressure Gauge
3 Perpipaan
R. Aula Rapat
4 Sambungan selang
5 Kondisi kabinet
6 Isi kabinet Hydrant

1 Control valve
2 Pressure Gauge
3 Perpipaan
R. Management
4 Sambungan selang
5 Kondisi kabinet
6 Isi kabinet Hydrant

1 Control valve
2 Pressure Gauge
3 Perpipaan
Nurse Station
4 Sambungan selang
5 Kondisi kabinet
 Nurse Station

6 Isi kabinet Hydrant

1 Control valve
2 Pressure Gauge
3 Perpipaan
Nurse Station
4 Sambungan selang
5 Kondisi kabinet
6 Isi kabinet Hydrant

1 Control valve
2 Pressure Gauge
3 Perpipaan
Nurse Station
4 Sambungan selang
5 Kondisi kabinet
6 Isi kabinet Hydrant

1 Control valve
2 Pressure Gauge
3 Perpipaan
Nurse Station
4 Sambungan selang
5 Kondisi kabinet
6 Isi kabinet Hydrant

1 Control valve
2 Pressure Gauge
3 Perpipaan
Nurse Station (R. Rawat VIP)
4 Sambungan selang
5 Kondisi kabinet
6 Isi kabinet Hydrant

1 Control valve
2 Pressure Gauge
3 Perpipaan
Nurse Station (R. Rawat VIP)
4 Sambungan selang
5 Kondisi kabinet
6 Isi kabinet Hydrant

1 Control valve
2 Pressure Gauge
3 Perpipaan
4 Sambungan selang
5 Kondisi kabinet
6 Isi kabinet Hydrant
Aula Besar
 Aula Besar
1 Control valve
2 Pressure Gauge
3 Perpipaan
4 Sambungan selang
5 Kondisi kabinet
6 Isi kabinet Hydrant
ARI Paraf
K3RS
SEP OKT NOV DES BULAN: JAN FEB
KONDISI
Lantai Gedung No Ceklist Item
Baik Rusak
√ 1 Control valve
√ 2 Pressure Gauge
√ 3 Perpipaan
√ 4 Sambungan selang
√ 5 Kondisi kabinet
√ 6 Isi kabinet Hydrant
2
√ 1 Control valve
√ 2 Pressure Gauge
√ 3 Perpipaan
√ 4 Sambungan selang
√ 5 Kondisi kabinet
√ 6 Isi kabinet Hydrant
1
√ 1 Control valve
√ 2 Pressure Gauge
√ 3 Perpipaan
√ 4 Sambungan selang
√ 5 Kondisi kabinet
√ 6 Isi kabinet Hydrant
1
√ 1 Control valve
√ 2 Pressure Gauge
√ 3 Perpipaan
√ 4 Sambungan selang
√ 5 Kondisi kabinet
√ 6 Isi kabinet Hydrant

ARI Paraf
K3RS
SEP OKT NOV DES BULAN: JAN FEB
KONDISI
Lantai Gedung No Ceklist Item
Baik Rusak
 √ 1 Control valve
√ 2 Pressure Gauge
√ 3 Perpipaan
1
√ 4 Sambungan selang
√ 5 Kondisi kabinet
√ 6 Isi kabinet Hydrant

√ 1 Control valve
√ 2 Pressure Gauge
√ 3 Perpipaan
5 2
√ 4 Sambungan selang
√ 5 Kondisi kabinet
√ 6 Isi kabinet Hydrant

√ 1 Control valve
√ 2 Pressure Gauge
√ 3 Perpipaan
2
√ 4 Sambungan selang
√ 5 Kondisi kabinet
√ 6 Isi kabinet Hydrant

ARI Paraf
K3RS
SEP OKT NOV DES BULAN: JAN FEB
KONDISI
Lantai Gedung No Ceklist Item
Baik Rusak
√ 1 Control valve
√ 2 Pressure Gauge
√ 3 Perpipaan
√ 4 Sambungan selang
√ 5 Kondisi kabinet
√ 6 Isi kabinet Hydrant
1
√ 1 Control valve
√ 2 Pressure Gauge
 1

√ 3 Perpipaan
√ 4 Sambungan selang
√ 5 Kondisi kabinet
√ 6 Isi kabinet Hydrant
4
√ 1 Control valve
√ 2 Pressure Gauge
√ 3 Perpipaan
√ 4 Sambungan selang
√ 5 Kondisi kabinet
√ 6 Isi kabinet Hydrant
2
√ 1 Control valve
√ 2 Pressure Gauge
√ 3 Perpipaan
√ 4 Sambungan selang
√ 5 Kondisi kabinet
√ 6 Isi kabinet Hydrant

1 Control valve
2 Pressure Gauge
ARI Paraf
K3RS 3 Perpipaan
SEP OKT NOV DES 4 Sambungan selang
KONDISI 5 Kondisi kabinet
Lantai Gedung
Baik Rusak 6 Isi kabinet Hydrant
√
√ 1 Control valve
√ 2 Pressure Gauge
√ 3 Perpipaan
√ 4 Sambungan selang
√ 5 Kondisi kabinet
6 Isi kabinet Hydrant
√
√ 1 Control valve
√ 2 Pressure Gauge
1
√ 3 Perpipaan
√ 4 Sambungan selang
√ 5 Kondisi kabinet
6 Isi kabinet Hydrant
√
√
√
√
 √ BULAN: JAN FEB
√
No Ceklist Item

√ 1 Control valve
√ 2 Pressure Gauge
√ 3 Perpipaan
2
√ 4 Sambungan selang
√ 5 Kondisi kabinet
√ 6 Isi kabinet Hydrant

√ 1 Control valve
√ 2 Pressure Gauge
√ 3 Perpipaan
√ 4 Sambungan selang
√ 5 Kondisi kabinet
√ 6 Isi kabinet Hydrant
3
√ 1 Control valve
√ 2 Pressure Gauge
√ 3 Perpipaan
√ 4 Sambungan selang
√ 5 Kondisi kabinet
√ 6 Isi kabinet Hydrant

√ 1 Control valve
√ 2 Pressure Gauge
√ 3 Perpipaan
√ 4 Sambungan selang
√ 5 Kondisi kabinet
√ 6 Isi kabinet Hydrant
4
√ 1 Control valve
√ 2 Pressure Gauge
√ 3 Perpipaan
√ 4 Sambungan selang
√ 5 Kondisi kabinet
√ 6 Isi kabinet Hydrant
3
√ 1 Control valve
√ 2 Pressure Gauge
√ 3 Perpipaan
√ 4 Sambungan selang
√ 5 Kondisi kabinet

5
 √ 6 Isi kabinet Hydrant
5
√
√
√
√ BULAN: JAN FEB
√
No Ceklist Item
√
1 Control valve
√ 2 Pressure Gauge
√ 3 Perpipaan
√ 4 Sambungan selang
√ 5 Kondisi kabinet
√ 6 Isi kabinet Hydrant
√
6 1 Control valve
√ 2 Pressure Gauge
√ 3 Perpipaan
√ 4 Sambungan selang
√ 5 Kondisi kabinet
√ 6 Isi kabinet Hydrant
√
1 Control valve
√ 2 Pressure Gauge
√ 3 Perpipaan
√ 4 Sambungan selang
√ 5 Kondisi kabinet
√ 6 Isi kabinet Hydrant
√
7 1 Control valve
√ 2 Pressure Gauge
√ 3 Perpipaan
√ 4 Sambungan selang
√ 5 Kondisi kabinet
√ 6 Isi kabinet Hydrant
√

√
√
√
√
√
√
8
8
√
√
√
√
√
√
 INSPEKSI HYDRANT SETIAP 30 HARI

MAR APR MEI JUN JUL AGS SEP OKT NOV DES

Ceklist Item Lokasi Hydrant Lantai Gedung

alve

n
Isolasi paru
an selang

1
alve
Gauge
n
Belakang isolasi paru
an selang
abinet
t Hydrant
3
alve
Gauge
n
Klinik anak
an selang
abinet
t Hydrant
2
alve
Gauge
n
Connecting bedah umum
an selang
abinet
t Hydrant

INSPEKSI HYDRANT SETIAP 30 HARI

MAR APR MEI JUN JUL AGS SEP OKT NOV DES

Ceklist Item Lokasi Hydrant Lantai Gedung

alve

n
Poli DM
an selang

2
alve
Gauge
n
Depan VK 3 2
an selang
abinet
t Hydrant

alve
Gauge
n
ICU covid 1
an selang
abinet
t Hydrant

INSPEKSI HYDRANT SETIAP 30 HARI

MAR APR MEI JUN JUL AGS SEP OKT NOV DES

Ceklist Item Lokasi Hydrant Lantai Gedung

alve

n
Lobby
an selang

alve
Gauge

Depan UGD (Lama)

n
Depan UGD (Lama)
an selang
abinet
t Hydrant

alve
Gauge
n
Samping WTP
an selang
abinet
t Hydrant

alve
Gauge
n Luar
Depan Masjid 1
an selang Gedung
abinet
t Hydrant

alve
Gauge
n
an selang
abinet
t Hydrant

alve
Gauge
n
Parkir Mobil
an selang
abinet
t Hydrant

alve
Gauge
n
an selang
abinet
t Hydrant

INSPEKSI HYDRANT SETIAP 30 HARI

 MAR APR MEI JUN JUL AGS SEP OKT NOV DES

Ceklist Item Lokasi Hydrant Lantai Gedung

alve

n
an selang

alve
Gauge
n
an selang
abinet
t Hydrant

alve
Gauge
n
an selang
abinet
t Hydrant
Luar
Parkir Gedung 3&4 1
Gedung
alve
Gauge
n
an selang
abinet
t Hydrant

alve
Gauge
n
an selang
abinet
t Hydrant

alve
Gauge
n
an selang
abinet
t Hydrant

INSPEKSI HYDRANT SETIAP 30 HARI

MAR APR MEI JUN JUL AGS SEP OKT NOV DES

Ceklist Item Lokasi Hydrant Lantai Gedung

alve

n
Selasar Linen 1
an selang

alve
Gauge
n
Depan R. Control 2
an selang
abinet
t Hydrant
4 (Linen)
alve
Gauge
n
R. Farmasi 3
an selang
abinet
t Hydrant

alve
Gauge
n
Depan Gudang Galon Gizi 4
an selang
abinet
t Hydrant
 Paraf
K3RS

KONDISI
Baik Rusak
√
√
√
√
√
√

√
√
√
√
√
√

√
√
√
√
√
√

√
√
√
√
√
√

Paraf
K3RS

KONDISI
Baik Rusak
√
√
√
√
√
√

√
√
√
√
√
√

√
√
√
√
√
√

Paraf
K3RS

KONDISI
Baik Rusak
√
√
√
√
√
√

√
√
√
√
√
√

√
√
√
√
√
√

√
√
√
√
√
√

√
√
√
√
√
√

√
√
√
√
√
√

√
√
√
√
√
√

Paraf
K3RS
 Paraf
K3RS

KONDISI
Baik Rusak
√
√
√
√
√
√

√
√
√
√
√
√

√
√
√
√
√
√

√
√
√
√
√
√

√
√
√
√
√
√

√
√
√
√
√
√

Paraf
K3RS

KONDISI
Baik Rusak
√
√
√
√
√
√

√
√
√
√
√
√

√
√
√
√
√
√

√
√
√
√
√
√
 INSPEKSI HYDRANT SETIAP 30 HARI

BULAN: JAN FEB MAR APR MEI JUN JUL AGS

No Ceklist Item Lokasi Hydrant

1 Control valve
2 Pressure Gauge
3 Perpipaan
Klinik orthopedi
4 Sambungan selang
5 Kondisi kabinet
6 Isi kabinet Hydrant

1 Control valve
2 Pressure Gauge
3 Perpipaan
Depan pendaftaran BPJS
4 Sambungan selang
5 Kondisi kabinet
6 Isi kabinet Hydrant

1 Control valve
2 Pressure Gauge
3 Perpipaan
Depan toilet belakang IGD lama
4 Sambungan selang
5 Kondisi kabinet
6 Isi kabinet Hydrant

1 Control valve
2 Pressure Gauge
3 Perpipaan IGD lama (Kondisi terhalang baby
4 Sambungan selang incubator)
5 Kondisi kabinet
6 Isi kabinet Hydrant

INSPEKSI HYDRANT SETIAP 30 HARI

BULAN: JAN FEB MAR APR MEI JUN JUL AGS

No Ceklist Item Lokasi Hydrant

 1 Control valve
2 Pressure Gauge
3 Perpipaan
Depan poliklinik rehab medik
4 Sambungan selang
5 Kondisi kabinet
6 Isi kabinet Hydrant

1 Control valve
2 Pressure Gauge
3 Perpipaan
Aula komite medik
4 Sambungan selang
5 Kondisi kabinet
6 Isi kabinet Hydrant

1 Control valve
2 Pressure Gauge
3 Perpipaan
Rekam medik
4 Sambungan selang
5 Kondisi kabinet
6 Isi kabinet Hydrant

INSPEKSI HYDRANT SETIAP 30 HARI

BULAN: JAN FEB MAR APR MEI JUN JUL AGS

No Ceklist Item Lokasi Hydrant

1 Control valve
2 Pressure Gauge
3 Perpipaan
Wing covid
4 Sambungan selang
5 Kondisi kabinet
6 Isi kabinet Hydrant

1 Control valve
2 Pressure Gauge

Belakang wing covid

 3 Perpipaan
Belakang wing covid
4 Sambungan selang
5 Kondisi kabinet
6 Isi kabinet Hydrant

1 Control valve
2 Pressure Gauge
3 Perpipaan
Poli B20
4 Sambungan selang
5 Kondisi kabinet
6 Isi kabinet Hydrant

1 Control valve
2 Pressure Gauge
3 Perpipaan
Ruang RO
4 Sambungan selang
5 Kondisi kabinet
6 Isi kabinet Hydrant

INSPEKSI HYDRANT SETIAP 30 HARI

BULAN: JAN FEB MAR APR MEI JUN JUL AGS

No Ceklist Item Lokasi Hydrant

1 Control valve
2 Pressure Gauge
3 Perpipaan
IGD Baru
4 Sambungan selang
5 Kondisi kabinet
6 Isi kabinet Hydrant

1 Control valve
2 Pressure Gauge
3 Perpipaan
R. Radiologi
4 Sambungan selang
5 Kondisi kabinet
6 Isi kabinet Hydrant

1 Control valve
2 Pressure Gauge
3 Perpipaan
Laboratorium
4 Sambungan selang
 Laboratorium

5 Kondisi kabinet
6 Isi kabinet Hydrant

1 Control valve
2 Pressure Gauge
3 Perpipaan
PICU
4 Sambungan selang
5 Kondisi kabinet
6 Isi kabinet Hydrant

1 Control valve
2 Pressure Gauge
3 Perpipaan
Dalam R. OK
4 Sambungan selang
5 Kondisi kabinet
6 Isi kabinet Hydrant

1 Control valve
2 Pressure Gauge
3 Perpipaan
Dalam R. CSSD
4 Sambungan selang
5 Kondisi kabinet
6 Isi kabinet Hydrant

1 Control valve
2 Pressure Gauge
3 Perpipaan
R. Aula Rapat
4 Sambungan selang
5 Kondisi kabinet
6 Isi kabinet Hydrant

1 Control valve
2 Pressure Gauge
3 Perpipaan
R. Management
4 Sambungan selang
5 Kondisi kabinet
6 Isi kabinet Hydrant

1 Control valve
2 Pressure Gauge
3 Perpipaan
Nurse Station
4 Sambungan selang
5 Kondisi kabinet
 Nurse Station

6 Isi kabinet Hydrant

1 Control valve
2 Pressure Gauge
3 Perpipaan
Nurse Station
4 Sambungan selang
5 Kondisi kabinet
6 Isi kabinet Hydrant

1 Control valve
2 Pressure Gauge
3 Perpipaan
Nurse Station
4 Sambungan selang
5 Kondisi kabinet
6 Isi kabinet Hydrant

1 Control valve
2 Pressure Gauge
3 Perpipaan
Nurse Station
4 Sambungan selang
5 Kondisi kabinet
6 Isi kabinet Hydrant

1 Control valve
2 Pressure Gauge
3 Perpipaan
Nurse Station (R. Rawat VIP)
4 Sambungan selang
5 Kondisi kabinet
6 Isi kabinet Hydrant

1 Control valve
2 Pressure Gauge
3 Perpipaan
Nurse Station (R. Rawat VIP)
4 Sambungan selang
5 Kondisi kabinet
6 Isi kabinet Hydrant

1 Control valve
2 Pressure Gauge
3 Perpipaan
4 Sambungan selang
5 Kondisi kabinet
6 Isi kabinet Hydrant
Aula Besar
 Aula Besar
1 Control valve
2 Pressure Gauge
3 Perpipaan
4 Sambungan selang
5 Kondisi kabinet
6 Isi kabinet Hydrant
ARI Paraf
K3RS
SEP OKT NOV DES BULAN: JAN FEB
KONDISI
Lantai Gedung No Ceklist Item
Baik Rusak
√ 1 Control valve
√ 2 Pressure Gauge
√ 3 Perpipaan
√ 4 Sambungan selang
√ 5 Kondisi kabinet
√ 6 Isi kabinet Hydrant
2
√ 1 Control valve
√ 2 Pressure Gauge
√ 3 Perpipaan
√ 4 Sambungan selang
√ 5 Kondisi kabinet
√ 6 Isi kabinet Hydrant
1
√ 1 Control valve
√ 2 Pressure Gauge
√ 3 Perpipaan
√ 4 Sambungan selang
√ 5 Kondisi kabinet
√ 6 Isi kabinet Hydrant
1
√ 1 Control valve
√ 2 Pressure Gauge
√ 3 Perpipaan
√ 4 Sambungan selang
√ 5 Kondisi kabinet
√ 6 Isi kabinet Hydrant

ARI Paraf
K3RS
SEP OKT NOV DES BULAN: JAN FEB
KONDISI
Lantai Gedung No Ceklist Item
Baik Rusak
 √ 1 Control valve
√ 2 Pressure Gauge
√ 3 Perpipaan
1
√ 4 Sambungan selang
√ 5 Kondisi kabinet
√ 6 Isi kabinet Hydrant

√ 1 Control valve
√ 2 Pressure Gauge
√ 3 Perpipaan
5 2
√ 4 Sambungan selang
√ 5 Kondisi kabinet
√ 6 Isi kabinet Hydrant

√ 1 Control valve
√ 2 Pressure Gauge
√ 3 Perpipaan
2
√ 4 Sambungan selang
√ 5 Kondisi kabinet
√ 6 Isi kabinet Hydrant

ARI Paraf
K3RS
SEP OKT NOV DES BULAN: JAN FEB
KONDISI
Lantai Gedung No Ceklist Item
Baik Rusak
√ 1 Control valve
√ 2 Pressure Gauge
√ 3 Perpipaan
√ 4 Sambungan selang
√ 5 Kondisi kabinet
√ 6 Isi kabinet Hydrant
1
√ 1 Control valve
√ 2 Pressure Gauge
 1

√ 3 Perpipaan
√ 4 Sambungan selang
√ 5 Kondisi kabinet
√ 6 Isi kabinet Hydrant
4
√ 1 Control valve
√ 2 Pressure Gauge
√ 3 Perpipaan
√ 4 Sambungan selang
√ 5 Kondisi kabinet
√ 6 Isi kabinet Hydrant
2
√ 1 Control valve
√ 2 Pressure Gauge
√ 3 Perpipaan
√ 4 Sambungan selang
√ 5 Kondisi kabinet
√ 6 Isi kabinet Hydrant

1 Control valve
2 Pressure Gauge
ARI Paraf
K3RS 3 Perpipaan
SEP OKT NOV DES 4 Sambungan selang
KONDISI 5 Kondisi kabinet
Lantai Gedung
Baik Rusak 6 Isi kabinet Hydrant
√
√ 1 Control valve
√ 2 Pressure Gauge
√ 3 Perpipaan
√ 4 Sambungan selang
√ 5 Kondisi kabinet
6 Isi kabinet Hydrant
√
√ 1 Control valve
√ 2 Pressure Gauge
1
√ 3 Perpipaan
√ 4 Sambungan selang
√ 5 Kondisi kabinet
6 Isi kabinet Hydrant
√
√
√
√
 √ BULAN: JAN FEB
√
No Ceklist Item

√ 1 Control valve
√ 2 Pressure Gauge
√ 3 Perpipaan
2
√ 4 Sambungan selang
√ 5 Kondisi kabinet
√ 6 Isi kabinet Hydrant

√ 1 Control valve
√ 2 Pressure Gauge
√ 3 Perpipaan
√ 4 Sambungan selang
√ 5 Kondisi kabinet
√ 6 Isi kabinet Hydrant
3
√ 1 Control valve
√ 2 Pressure Gauge
√ 3 Perpipaan
√ 4 Sambungan selang
√ 5 Kondisi kabinet
√ 6 Isi kabinet Hydrant

√ 1 Control valve
√ 2 Pressure Gauge
√ 3 Perpipaan
√ 4 Sambungan selang
√ 5 Kondisi kabinet
√ 6 Isi kabinet Hydrant
4
√ 1 Control valve
√ 2 Pressure Gauge
√ 3 Perpipaan
√ 4 Sambungan selang
√ 5 Kondisi kabinet
√ 6 Isi kabinet Hydrant
3
√ 1 Control valve
√ 2 Pressure Gauge
√ 3 Perpipaan
√ 4 Sambungan selang
√ 5 Kondisi kabinet

5
 √ 6 Isi kabinet Hydrant
5
√
√
√
√ BULAN: JAN FEB
√
No Ceklist Item
√
1 Control valve
√ 2 Pressure Gauge
√ 3 Perpipaan
√ 4 Sambungan selang
√ 5 Kondisi kabinet
√ 6 Isi kabinet Hydrant
√
6 1 Control valve
√ 2 Pressure Gauge
√ 3 Perpipaan
√ 4 Sambungan selang
√ 5 Kondisi kabinet
√ 6 Isi kabinet Hydrant
√
1 Control valve
√ 2 Pressure Gauge
√ 3 Perpipaan
√ 4 Sambungan selang
√ 5 Kondisi kabinet
√ 6 Isi kabinet Hydrant
√
7 1 Control valve
√ 2 Pressure Gauge
√ 3 Perpipaan
√ 4 Sambungan selang
√ 5 Kondisi kabinet
√ 6 Isi kabinet Hydrant
√

√
√
√
√
√
√
8
8
√
√
√
√
√
√
 INSPEKSI HYDRANT SETIAP 30 HARI

MAR APR MEI JUN JUL AGS SEP OKT NOV DES

Ceklist Item Lokasi Hydrant Lantai Gedung

alve

n
Isolasi paru
an selang

1
alve
Gauge
n
Belakang isolasi paru
an selang
abinet
t Hydrant
3
alve
Gauge
n
Klinik anak
an selang
abinet
t Hydrant
2
alve
Gauge
n
Connecting bedah umum
an selang
abinet
t Hydrant

INSPEKSI HYDRANT SETIAP 30 HARI

MAR APR MEI JUN JUL AGS SEP OKT NOV DES

Ceklist Item Lokasi Hydrant Lantai Gedung

alve

n
Poli DM
an selang

2
alve
Gauge
n
Depan VK 3 2
an selang
abinet
t Hydrant

alve
Gauge
n
ICU covid 1
an selang
abinet
t Hydrant

INSPEKSI HYDRANT SETIAP 30 HARI

MAR APR MEI JUN JUL AGS SEP OKT NOV DES

Ceklist Item Lokasi Hydrant Lantai Gedung

alve

n
Lobby
an selang

alve
Gauge

Depan UGD (Lama)

n
Depan UGD (Lama)
an selang
abinet
t Hydrant

alve
Gauge
n
Samping WTP
an selang
abinet
t Hydrant

alve
Gauge
n Luar
Depan Masjid 1
an selang Gedung
abinet
t Hydrant

alve
Gauge
n
an selang
abinet
t Hydrant

alve
Gauge
n
Parkir Mobil
an selang
abinet
t Hydrant

alve
Gauge
n
an selang
abinet
t Hydrant

INSPEKSI HYDRANT SETIAP 30 HARI

 MAR APR MEI JUN JUL AGS SEP OKT NOV DES

Ceklist Item Lokasi Hydrant Lantai Gedung

alve

n
an selang

alve
Gauge
n
an selang
abinet
t Hydrant

alve
Gauge
n
an selang
abinet
t Hydrant
Luar
Parkir Gedung 3&4 1
Gedung
alve
Gauge
n
an selang
abinet
t Hydrant

alve
Gauge
n
an selang
abinet
t Hydrant

alve
Gauge
n
an selang
abinet
t Hydrant

INSPEKSI HYDRANT SETIAP 30 HARI

MAR APR MEI JUN JUL AGS SEP OKT NOV DES

Ceklist Item Lokasi Hydrant Lantai Gedung

alve

n
Selasar Linen 1
an selang

alve
Gauge
n
Depan R. Control 2
an selang
abinet
t Hydrant
4 (Linen)
alve
Gauge
n
R. Farmasi 3
an selang
abinet
t Hydrant

alve
Gauge
n
Depan Gudang Galon Gizi 4
an selang
abinet
t Hydrant
 Paraf
K3RS

KONDISI
Baik Rusak
√
√
√
√
√
√

√
√
√
√
√
√

√
√
√
√
√
√

√
√
√
√
√
√

Paraf
K3RS

KONDISI
Baik Rusak
√
√
√
√
√
√

√
√
√
√
√
√

√
√
√
√
√
√

Paraf
K3RS

KONDISI
Baik Rusak
√
√
√
√
√
√

√
√
√
√
√
√

√
√
√
√
√
√

√
√
√
√
√
√

√
√
√
√
√
√

√
√
√
√
√
√

√
√
√
√
√
√

Paraf
K3RS
 Paraf
K3RS

KONDISI
Baik Rusak
√
√
√
√
√
√

√
√
√
√
√
√

√
√
√
√
√
√

√
√
√
√
√
√

√
√
√
√
√
√

√
√
√
√
√
√

Paraf
K3RS

KONDISI
Baik Rusak
√
√
√
√
√
√

√
√
√
√
√
√

√
√
√
√
√
√

√
√
√
√
√
√
 INSPEKSI HYDRANT SETIAP 30 HARI

BULAN: JAN FEB MAR APR MEI JUN JUL

No Ceklist Item Lokasi Hydrant

1 Control valve
2 Pressure Gauge
3 Perpipaan
Klinik orthopedi
4 Sambungan selang
5 Kondisi kabinet
6 Isi kabinet Hydrant

1 Control valve
2 Pressure Gauge
3 Perpipaan
Depan pendaftaran BPJS
4 Sambungan selang
5 Kondisi kabinet
6 Isi kabinet Hydrant

1 Control valve
2 Pressure Gauge
3 Perpipaan
Depan toilet belakang IGD lama
4 Sambungan selang
5 Kondisi kabinet
6 Isi kabinet Hydrant

1 Control valve
2 Pressure Gauge
3 Perpipaan IGD lama (Kondisi terhalang baby
4 Sambungan selang incubator)
5 Kondisi kabinet
6 Isi kabinet Hydrant

INSPEKSI HYDRANT SETIAP 30 HARI

BULAN: JAN FEB MAR APR MEI JUN JUL

No Ceklist Item Lokasi Hydrant

 No Ceklist Item Lokasi Hydrant

1 Control valve
2 Pressure Gauge
3 Perpipaan
Depan poliklinik rehab medik
4 Sambungan selang
5 Kondisi kabinet
6 Isi kabinet Hydrant

1 Control valve
2 Pressure Gauge
3 Perpipaan
Aula komite medik
4 Sambungan selang
5 Kondisi kabinet
6 Isi kabinet Hydrant

1 Control valve
2 Pressure Gauge
3 Perpipaan
Rekam medik
4 Sambungan selang
5 Kondisi kabinet
6 Isi kabinet Hydrant

INSPEKSI HYDRANT SETIAP 30 HARI

BULAN: JAN FEB MAR APR MEI JUN JUL

No Ceklist Item Lokasi Hydrant

1 Control valve
2 Pressure Gauge
3 Perpipaan
Wing covid
4 Sambungan selang
5 Kondisi kabinet
6 Isi kabinet Hydrant

1 Control valve

Belakang wing covid

 2 Pressure Gauge
3 Perpipaan
Belakang wing covid
4 Sambungan selang
5 Kondisi kabinet
6 Isi kabinet Hydrant

1 Control valve
2 Pressure Gauge
3 Perpipaan
Poli B20
4 Sambungan selang
5 Kondisi kabinet
6 Isi kabinet Hydrant

1 Control valve
2 Pressure Gauge
3 Perpipaan
Ruang RO
4 Sambungan selang
5 Kondisi kabinet
6 Isi kabinet Hydrant

INSPEKSI HYDRANT SETIAP 30 HARI

BULAN: JAN FEB MAR APR MEI JUN JUL

No Ceklist Item Lokasi Hydrant

1 Control valve
2 Pressure Gauge
3 Perpipaan
IGD Baru
4 Sambungan selang
5 Kondisi kabinet
6 Isi kabinet Hydrant

1 Control valve
2 Pressure Gauge
3 Perpipaan
R. Radiologi
4 Sambungan selang
5 Kondisi kabinet
6 Isi kabinet Hydrant

1 Control valve
2 Pressure Gauge
3 Perpipaan
Laboratorium
 Laboratorium
4 Sambungan selang
5 Kondisi kabinet
6 Isi kabinet Hydrant

1 Control valve
2 Pressure Gauge
3 Perpipaan
PICU
4 Sambungan selang
5 Kondisi kabinet
6 Isi kabinet Hydrant

1 Control valve
2 Pressure Gauge
3 Perpipaan
Dalam R. OK
4 Sambungan selang
5 Kondisi kabinet
6 Isi kabinet Hydrant

1 Control valve
2 Pressure Gauge
3 Perpipaan
Dalam R. CSSD
4 Sambungan selang
5 Kondisi kabinet
6 Isi kabinet Hydrant

1 Control valve
2 Pressure Gauge
3 Perpipaan
R. Aula Rapat
4 Sambungan selang
5 Kondisi kabinet
6 Isi kabinet Hydrant

1 Control valve
2 Pressure Gauge
3 Perpipaan
R. Management
4 Sambungan selang
5 Kondisi kabinet
6 Isi kabinet Hydrant

1 Control valve
2 Pressure Gauge
3 Perpipaan
Nurse Station
4 Sambungan selang
 Nurse Station

5 Kondisi kabinet
6 Isi kabinet Hydrant

1 Control valve
2 Pressure Gauge
3 Perpipaan
Nurse Station
4 Sambungan selang
5 Kondisi kabinet
6 Isi kabinet Hydrant

1 Control valve
2 Pressure Gauge
3 Perpipaan
Nurse Station
4 Sambungan selang
5 Kondisi kabinet
6 Isi kabinet Hydrant

1 Control valve
2 Pressure Gauge
3 Perpipaan
Nurse Station
4 Sambungan selang
5 Kondisi kabinet
6 Isi kabinet Hydrant

1 Control valve
2 Pressure Gauge
3 Perpipaan
Nurse Station (R. Rawat VIP)
4 Sambungan selang
5 Kondisi kabinet
6 Isi kabinet Hydrant

1 Control valve
2 Pressure Gauge
3 Perpipaan
Nurse Station (R. Rawat VIP)
4 Sambungan selang
5 Kondisi kabinet
6 Isi kabinet Hydrant

1 Control valve
2 Pressure Gauge
3 Perpipaan
4 Sambungan selang
5 Kondisi kabinet

Aula Besar
6 Isi kabinet Hydrant
Aula Besar
1 Control valve
2 Pressure Gauge
3 Perpipaan
4 Sambungan selang
5 Kondisi kabinet
6 Isi kabinet Hydrant
TIAP 30 HARI Paraf
K3RS
AGS SEP OKT NOV DES BULAN: JAN
KONDISI
Hydrant Lantai Gedung No Ceklist Item
Baik Rusak
√ 1 Control valve
√ 2 Pressure Gauge
√ 3 Perpipaan
rthopedi
√ 4 Sambungan selang
√ 5 Kondisi kabinet
√ 6 Isi kabinet Hydrant
2
√ 1 Control valve
√ 2 Pressure Gauge
√ 3 Perpipaan
daftaran BPJS
√ 4 Sambungan selang
√ 5 Kondisi kabinet
√ 6 Isi kabinet Hydrant
1
√ 1 Control valve
√ 2 Pressure Gauge
√ 3 Perpipaan
elakang IGD lama
√ 4 Sambungan selang
√ 5 Kondisi kabinet
√ 6 Isi kabinet Hydrant
1
√ 1 Control valve
√ 2 Pressure Gauge
si terhalang baby √ 3 Perpipaan
bator) √ 4 Sambungan selang
√ 5 Kondisi kabinet
√ 6 Isi kabinet Hydrant

TIAP 30 HARI Paraf

K3RS
AGS SEP OKT NOV DES BULAN: JAN
KONDISI
Hydrant Lantai Gedung No Ceklist Item
 Hydrant Lantai Gedung No Ceklist Item
Baik Rusak
√ 1 Control valve
√ 2 Pressure Gauge
√ 3 Perpipaan
nik rehab medik 1
√ 4 Sambungan selang
√ 5 Kondisi kabinet
√ 6 Isi kabinet Hydrant

√ 1 Control valve
√ 2 Pressure Gauge
√ 3 Perpipaan
mite medik 5 2
√ 4 Sambungan selang
√ 5 Kondisi kabinet
√ 6 Isi kabinet Hydrant

√ 1 Control valve
√ 2 Pressure Gauge
√ 3 Perpipaan
m medik 2
√ 4 Sambungan selang
√ 5 Kondisi kabinet
√ 6 Isi kabinet Hydrant

TIAP 30 HARI Paraf

K3RS
AGS SEP OKT NOV DES BULAN: JAN
KONDISI
Hydrant Lantai Gedung No Ceklist Item
Baik Rusak
√ 1 Control valve
√ 2 Pressure Gauge
√ 3 Perpipaan
g covid
√ 4 Sambungan selang
√ 5 Kondisi kabinet
√ 6 Isi kabinet Hydrant
1
√ 1 Control valve

wing covid
 1

√ 2 Pressure Gauge
√ 3 Perpipaan
wing covid
√ 4 Sambungan selang
√ 5 Kondisi kabinet
√ 6 Isi kabinet Hydrant
4
√ 1 Control valve
√ 2 Pressure Gauge
√ 3 Perpipaan
i B20
√ 4 Sambungan selang
√ 5 Kondisi kabinet
√ 6 Isi kabinet Hydrant
2
√ 1 Control valve
√ 2 Pressure Gauge
√ 3 Perpipaan
ng RO
√ 4 Sambungan selang
√ 5 Kondisi kabinet
√ 6 Isi kabinet Hydrant

1 Control valve
2 Pressure Gauge
TIAP 30 HARI Paraf
K3RS 3 Perpipaan
AGS SEP OKT NOV DES 4 Sambungan selang
KONDISI 5 Kondisi kabinet
Hydrant Lantai Gedung
Baik Rusak 6 Isi kabinet Hydrant
√
√ 1 Control valve
√ 2 Pressure Gauge
Baru
√ 3 Perpipaan
√ 4 Sambungan selang
√ 5 Kondisi kabinet
6 Isi kabinet Hydrant
√
√ 1 Control valve
√ 2 Pressure Gauge
diologi 1
√ 3 Perpipaan
√ 4 Sambungan selang
√ 5 Kondisi kabinet
6 Isi kabinet Hydrant
√
√
√
atorium
atorium
√
√ BULAN: JAN
√
No Ceklist Item

√ 1 Control valve
√ 2 Pressure Gauge
√ 3 Perpipaan
CU 2
√ 4 Sambungan selang
√ 5 Kondisi kabinet
√ 6 Isi kabinet Hydrant

√ 1 Control valve
√ 2 Pressure Gauge
√ 3 Perpipaan
m R. OK
√ 4 Sambungan selang
√ 5 Kondisi kabinet
√ 6 Isi kabinet Hydrant
3
√ 1 Control valve
√ 2 Pressure Gauge
√ 3 Perpipaan
R. CSSD
√ 4 Sambungan selang
√ 5 Kondisi kabinet
√ 6 Isi kabinet Hydrant

√ 1 Control valve
√ 2 Pressure Gauge
√ 3 Perpipaan
a Rapat
√ 4 Sambungan selang
√ 5 Kondisi kabinet
√ 6 Isi kabinet Hydrant
4
√ 1 Control valve
√ 2 Pressure Gauge
√ 3 Perpipaan
agement
√ 4 Sambungan selang
√ 5 Kondisi kabinet
√ 6 Isi kabinet Hydrant
3
√ 1 Control valve
√ 2 Pressure Gauge
√ 3 Perpipaan
Station
√ 4 Sambungan selang

5
Station

√ 5 Kondisi kabinet
√ 6 Isi kabinet Hydrant
5
√
√
√
Station
√ BULAN: JAN
√
No Ceklist Item
√
1 Control valve
√ 2 Pressure Gauge
√ 3 Perpipaan
√ 4 Sambungan selang
Station
√ 5 Kondisi kabinet
√ 6 Isi kabinet Hydrant
√
6 1 Control valve
√ 2 Pressure Gauge
√ 3 Perpipaan
√ 4 Sambungan selang
Station
√ 5 Kondisi kabinet
√ 6 Isi kabinet Hydrant
√
1 Control valve
√ 2 Pressure Gauge
√ 3 Perpipaan
√ 4 Sambungan selang
(R. Rawat VIP)
√ 5 Kondisi kabinet
√ 6 Isi kabinet Hydrant
√
7 1 Control valve
√ 2 Pressure Gauge
√ 3 Perpipaan
√ 4 Sambungan selang
(R. Rawat VIP)
√ 5 Kondisi kabinet
√ 6 Isi kabinet Hydrant
√

√
√
√
√
√

Besar 8
 √
Besar 8
√
√
√
√
√
√
 INSPEKSI HYDRANT SETIAP 30 HARI

FEB MAR APR MEI JUN JUL AGS SEP OKT NOV

Ceklist Item Lokasi Hydrant Lantai Gedung

Control valve
Pressure Gauge
Perpipaan
Isolasi paru
Sambungan selang
Kondisi kabinet
Isi kabinet Hydrant
1
Control valve
Pressure Gauge
Perpipaan
Belakang isolasi paru
Sambungan selang
Kondisi kabinet
Isi kabinet Hydrant
3
Control valve
Pressure Gauge
Perpipaan
Klinik anak
Sambungan selang
Kondisi kabinet
Isi kabinet Hydrant
2
Control valve
Pressure Gauge
Perpipaan
Connecting bedah umum
Sambungan selang
Kondisi kabinet
Isi kabinet Hydrant

INSPEKSI HYDRANT SETIAP 30 HARI

FEB MAR APR MEI JUN JUL AGS SEP OKT NOV

Ceklist Item Lokasi Hydrant Lantai Gedung

 Ceklist Item Lokasi Hydrant Lantai Gedung

Control valve
Pressure Gauge
Perpipaan
Poli DM
Sambungan selang
Kondisi kabinet
Isi kabinet Hydrant
2
Control valve
Pressure Gauge
Perpipaan
Depan VK 3 2
Sambungan selang
Kondisi kabinet
Isi kabinet Hydrant

Control valve
Pressure Gauge
Perpipaan
ICU covid 1
Sambungan selang
Kondisi kabinet
Isi kabinet Hydrant

INSPEKSI HYDRANT SETIAP 30 HARI

FEB MAR APR MEI JUN JUL AGS SEP OKT NOV

Ceklist Item Lokasi Hydrant Lantai Gedung

Control valve
Pressure Gauge
Perpipaan
Lobby
Sambungan selang
Kondisi kabinet
Isi kabinet Hydrant

Control valve

Depan UGD (Lama)

Pressure Gauge
Perpipaan
Depan UGD (Lama)
Sambungan selang
Kondisi kabinet
Isi kabinet Hydrant

Control valve
Pressure Gauge
Perpipaan
Samping WTP
Sambungan selang
Kondisi kabinet
Isi kabinet Hydrant

Control valve
Pressure Gauge
Perpipaan Luar
Depan Masjid 1
Sambungan selang Gedung
Kondisi kabinet
Isi kabinet Hydrant

Control valve
Pressure Gauge
Perpipaan
Sambungan selang
Kondisi kabinet
Isi kabinet Hydrant

Control valve
Pressure Gauge
Perpipaan
Parkir Mobil
Sambungan selang
Kondisi kabinet
Isi kabinet Hydrant

Control valve
Pressure Gauge
Perpipaan
Sambungan selang
Kondisi kabinet
Isi kabinet Hydrant

INSPEKSI HYDRANT SETIAP 30 HARI

 INSPEKSI HYDRANT SETIAP 30 HARI

FEB MAR APR MEI JUN JUL AGS SEP OKT NOV

Ceklist Item Lokasi Hydrant Lantai Gedung

Control valve
Pressure Gauge
Perpipaan
Sambungan selang
Kondisi kabinet
Isi kabinet Hydrant

Control valve
Pressure Gauge
Perpipaan
Sambungan selang
Kondisi kabinet
Isi kabinet Hydrant

Control valve
Pressure Gauge
Perpipaan
Sambungan selang
Kondisi kabinet
Isi kabinet Hydrant
Parkir Gedung 3&4 1 Luar
Gedung
Control valve
Pressure Gauge
Perpipaan
Sambungan selang
Kondisi kabinet
Isi kabinet Hydrant

Control valve
Pressure Gauge
Perpipaan
Sambungan selang
Kondisi kabinet
Isi kabinet Hydrant

Control valve
Pressure Gauge
Perpipaan
Sambungan selang
Kondisi kabinet
Isi kabinet Hydrant

INSPEKSI HYDRANT SETIAP 30 HARI

FEB MAR APR MEI JUN JUL AGS SEP OKT NOV

Ceklist Item Lokasi Hydrant Lantai Gedung

Control valve
Pressure Gauge
Perpipaan
Selasar Linen 1
Sambungan selang
Kondisi kabinet
Isi kabinet Hydrant

Control valve
Pressure Gauge
Perpipaan
Depan R. Control 2
Sambungan selang
Kondisi kabinet
Isi kabinet Hydrant
4 (Linen)
Control valve
Pressure Gauge
Perpipaan
R. Farmasi 3
Sambungan selang
Kondisi kabinet
Isi kabinet Hydrant

Control valve
Pressure Gauge
Perpipaan
Depan Gudang Galon Gizi 4
Sambungan selang
Kondisi kabinet
Isi kabinet Hydrant
 Paraf
K3RS
DES
KONDISI
Gedung
Baik Rusak
√
√
√
√
√
√
1
√
√
√
√
√
√

√
√
√
√
√
√
2
√
√
√
√
√
√

Paraf
K3RS
DES
KONDISI
Gedung
Gedung
Baik Rusak
√
√
√
√
√
√
2
√
√
√
√
√
√

√
√
√
1
√
√
√

Paraf
K3RS
DES
KONDISI
Gedung
Baik Rusak
√
√
√
√
√
√

√
 √
√
√
√
√

√
√
√
√
√
√

√
√
Luar √
Gedung √
√
√

√
√
√
√
√
√

√
√
√
√
√
√

√
√
√
√
√
√

Paraf
K3RS
 Paraf
K3RS
DES
KONDISI
Gedung
Baik Rusak
√
√
√
√
√
√

√
√
√
√
√
√

√
√
√
√
√
√
Luar
Gedung
√
√
√
√
√
√

√
√
√
√
√
√

√
√
√
√
 √
√

Paraf
K3RS
DES
KONDISI
Gedung
Baik Rusak
√
√
√
√
√
√

√
√
√
√
√
√
4 (Linen)
√
√
√
√
√
√

√
√
√
√
√
√