Loogboog .............

Nama Perusahaan / Faskes

Bulan : ................. 20....

No Tanggal Oli Jumlah

Bekas
1 Bulan Lalu 0 0
2 ....../......./20..... 0 0
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31

Jumlah (Kg) 0 0
Rata-rata perhari (kg) 0.00 0.00

Loogboog Lampu TL
UPT BLUD
PUSKESMAS DASAN LEKONG
Bulan :

No Tanggal Lampu TL Jumlah

 1 Bulan Lalu 0 0
2 0 0
3 0 0
4 0 0
5 0 0
6 0 0
7 0 0
8 0 0
9 0 0
10 0 0
11 0 0
12 0 0
13 0 0
14 0 0
15 0 0
16 0 0
17 0 0
18 0 0
19 0 0
20 0 0
21 0 0
22 0 0
23 0 0
24 0 0
25 0 0
26 0 0
27 0 0
28 0 0
29 0 0
30 0 0
31 0 0

Jumlah (Kg) 0 0

Rata-rata perhari (kg) 0.00 0.00

Loogboog Limbah Klinis

UPT BLUD
PUSKESMAS DASAN LEKONG
Bulan :

No Tanggal Limbah Klinis Jumlah

1 Bulan Lalu 0 0
2 0 0
3 0 0
4 0 0
 5 0 0
6 0 0
7 0 0
8 0 0
9 0 0
10 0 0
11 0 0
12 0 0
13 0 0
14 0 0
15 0 0
16 0 0
17 0 0
18 0 0
19 0 0
20 0 0
21 0 0
22 0 0
23 0 0
24 0 0
25 0 0
26 0 0
27 0 0
28 0 0
29 0 0
30 0 0
31 0 0

Jumlah (Kg) 0 0

Rata-rata perhari (kg) 0.00 0.00

Loogboog Limbah Kaca

UPT BLUD
PUSKESMAS DASAN LEKONG
Bulan :

No Tanggal Limbah Kaca Jumlah

1 Bulan Lalu 0 0
2 0 0
3 0 0
4 0 0
5 0 0
6 0 0
7 0 0
8 0 0
9 0 0
 10 0 0
11 0 0
12 0 0
13 0 0
14 0 0
15 0 0
16 0 0
17 0 0
18 0 0
19 0 0
20 0 0
21 0 0
22 0 0
23 0 0
24 0 0
25 0 0
26 0 0
27 0 0
28 0 0
29 0 0
30 0 0
31 0 0

Jumlah (Kg) 0 0

Rata-rata perhari (kg) 0.00 0.00

 Loogboog Cairan Fixer dan Dev
UPT BLUD
PUSKESMAS DASAN LEKONG
Bulan :

Keterangan No Tanggal Cairan Fixer Developer

Nihil 1 Bulan Lalu 0 0

Nihil 2 0 0
3 0 0
4 0 0
Keterangan
5 0 0
6 0 0
7 0 0
8 0 0
9 0 0
10 0 0
11 0 0
12 0 0
13 0 0
14 0 0
15 0 0
16 0 0
17 0 0
18 0 0
19 0 0
20 0 0
21 0 0
22 0 0
23 0 0
24 0 0
25 0 0
26 0 0
27 0 0
28 0 0
29 0 0
30 0 0
31 0 0
32

Nihi Jumlah (Kg) 0 0

l Rata-rata perhari (kg) 0.00 0.00

 Nihil
Nihil
Nihil
Nihil
Nihil
Nihil
Nihil
Nihil
Nihil
Nihil
Nihil
Nihil
Nihil
Nihil
Nihil
Nihil
Nihil
Nihil
Nihil
Nihil
Nihil
Nihil
Nihil
Nihil
Nihil
Nihil
Nihil
Nihil
Nihil
Nihil
Nihil

Nihi

Nihi

Keterangan

Nihil
Nihil
Nihil
Nihil
 Nihil
Nihil
Nihil
Nihil
Nihil
Nihil
Nihil
Nihil
Nihil
Nihil
Nihil
Nihil
Nihil
Nihil
Nihil
Nihil
Nihil
Nihil
Nihil
Nihil
Nihil
Nihil
Nihil
Nihil
Nihil
Nihil
Nihil

Nihi

Nihi

Keterangan

Nihil
Nihil
Nihil
Nihil
Nihil
Nihil
Nihil
Nihil
Nihil
Nihil
Nihil
Nihil
Nihil
Nihil
Nihil
Nihil
Nihil
Nihil
Nihil
Nihil
Nihil
Nihil
Nihil
Nihil
Nihil
Nihil
Nihil
Nihil
Nihil
Nihil
Nihil

Nihi

Nihi

l
eloper
GORO

Jumlah Keterangan

0 Nihil
0 Nihil
0 Nihil
0 Nihil
0 Nihil
0 Nihil
0 Nihil
0 Nihil
0 Nihil
0 Nihil
0 Nihil
0 Nihil
0 Nihil
0 Nihil
0 Nihil
0 Nihil
0 Nihil
0 Nihil
0 Nihil
0 Nihil
0 Nihil
0 Nihil
0 Nihil
0 Nihil
0 Nihil
0 Nihil
0 Nihil
0 Nihil
0 Nihil
0 Nihil
0 Nihil

0 Nihi

0.00 l

Nihi

l
 :

Maksimal
Sumber Jumlah Sisa Limbah
Kode Limbah penyimpanan Jumlah Bukti Nomor
Tanggal masuk Limbah B3 Limbah B3 Tanggal keluar Tujuan B3 yang ada di
No. Jenis Limbah B3 Masuk sesuai PP s/d tanggal: Limbah B3 Dokumen
Limbah B3 [1] Masuk Limbah B3 Penyerahan TPS
101/2014 [2] (kg) [3]
(dalam kg) (kg) [ 4 ]

(A) (B) (C) (D) (E) (F) (G) (H) (I) (J) (K) (L)

1
2
3
4
5
6
7
8
9
10

. . . . . . . . . . . . . . . , 2022
Paraf Petugas

Keterangan :
[1]
Sumber kegiatan yang menghasilan limbah. Misal dari kegiatan sendiri berasal dari ruang operasi, ruang bengkel, dsb. ( )
[2]
Dokumen dapat berupa: manifest, atau dokumen internal perusahaan yang diserahkan dari bagian lain.
[3]
Batas waktu maksimal penyimpanan di TPS, misal untuk limbah infeksius maksimal 2x24 jam untuk suhu lebih dari 2°C, sesuai rekomendasi
[4]
Setiap lembar harap diparaf oleh Petugas yang bertanggung jawab.