FORM CHEKCLIST TANGKI PENYIMPANAN

Bulan :
Kondisi
No Uraian Standard Keterangan
√ X
Ground Water Tank

1 Warna Air Jernih

2 Endapan Lumpur Tidak Ada

3 Lumut Tidak Ada

4 Kebersihan Dinding Bagian Dalam

5 Kebocoran Tangki

6 Valve Outlet

7 Pipa Outlet

Tangki Air Lt. 9

1 Warna Air Jernih

2 Endapan Lumpur Tidak Ada

3 Lumut Tidak Ada

4 Kebersihan Dinding Bagian Dalam

5 Kebocoran Tangki

6 Valve outlet

7 Pipa Outlet

Catatan :

dicek oleh

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NIK.
FORM CHECKLIST GAS MEDIS
Bulan :
Kondisi
No Uraian Standard Keterangan
√ X
VGL
1 Manifold
2 Kebocoran Pipa
3 Tekanan Tabung max 3.2 bar
3 Tekanan Outlet 4 - 5 bar
4 Fisik Tabung
Tangki Liquid Oksigen Cair
1 Kebocoran Pipa
3 Tekanan Tabung 5 - 12 bar
2 Tekanan Outlet 4 - 5 bar
3 Volume tangki >500
3 Alarm Sistem 4 - 7 bar
4 Fisik Tabung
Compressed Air
1 Tabung Air
2 Kebocoran Pipa
3 Kebocoran Tabung
4 Sistem Automatis
5 Tekanan 0.2 - 0.7 bar
6 Vacuum Machine -1 bar
N20
1 Manifold
2 Kebocoran Pipa
3 Tekanan Tabung 1000 psi
4 Tekanan Outlet 4 - 5 bar
5 Fisik Tabung
Tabung 6m3
1 Manifold
2 Kebocoran Pipa
3 Tekanan Tabung 1000 psi
4 Tekanan Outlet 4 - 5 bar
5 Fisik Tabung
Ruang Pasien
1 Outlet O2
2 Outlet Udara
3 Outlet Vacum
 Kondisi
No Uraian Standard Keterangan
√ X
CO2
1 Tekanan
2 Fisik Tabung
Tabung 1m3
1 Tekanan 1000 psi
2 Fisik Tabung
Tabung 1,5m3
1 Tekanan 1000 psi
2 Fisik Tabung

Catatan :
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NIK.
FORM CHEKLIST PENYALUR PETIR
Bulan :
Standar Kondisi Keterangan
No. Uraian
√ X

1 Perkabelan

2 Koneksi Kabel
3 Warning Light
4 Head Elektrostatik

5 Tiang Head Elektrostatik

6 Mounting Bolt < 5 ohm

7 Resistansi Pertanahan

Catatan :

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NIK.
FORM CHEKLIST BULANAN PUMP HOUSE
Bulan :
Kondisi
No. Uraian Standar Keterangan
√ X
Diesel Pump Fire Fighting

1 Volt Battery

2 Level Air Radiator

3 Level Oils

4 Kekencangan kabel baterai

5 Hourmeter (jam kerja)

6 Water separator primer
7 Water separator sekunder

8 Kebersihan diesel pump

9 Kebersihan filter udara

10 Kebocoran pipa solar
11 Kondisi valve isap
12 Kondisi valve discharge

13 Kondisi safety valve

14 Test running
15 Tekanan air 8 Bar
16 Strainer (filter pipa isap)

17 Posisi switch panel ( manual off auto )

18 Level solar

19 Level air aki

Electric Pump Fire Fighting

1 Kebersihan electro motor

2 Kondisi pompa
3 Tekanan Air 8 Bar

4 Ampere name plate

5 Kondisi panel electric pump

6 Kondisi valve isap
7 Kondisi valve discharge
8 Test run

9 Running Ampere R....S.....T.....

10 Stainer ( filter pipa isap )

11 Posisi switch panel ( Manual Off Auto )
12 Kebocoran Tidak ada
 Kondisi
No. Uraian Standar Keterangan
√ X
Jockey Pump Fire Fighting
1 Kebersihan electro motor
2 Kondisi pompa
3 Tekanan air 8 Bar

4 Ampere name plate

5 Kondisi panel electric pump

6 Kondisi valve isap
7 Kondisi valve discharge

8 Test run

9 Running Ampere R....S.....T.....

10 Stainer ( Filter Pipa Isap )

11 Posisi switch panel ( Manual Off Auto )

12 Kebocoran Tidak Ada

Catatan :

dicek oleh

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NIK.
Form Checklist Transfer Pump
Bulan :
Kondisi
No. Uraian Standar Keterangan
√ X
Transfer Pump 1 (Basement)
1 Kebersihan Electro Pump
2 Kondisi Pompa
3 Tekanan air 4 Bar
4 Ampere Name plate
5 Kondisi Panel Electric Pump
6 Kondisi Valve isap
7 Kondisi Valve Discharged
8 Test Run
9 Running ampere R....S....T
10 Strainer ( Filter Pipa Isap )
11 Posisi Switch panel ( Manual off auto ) Auto
Transfer Pump 2 (Basement)
1 Kebersihan Electro Pump
2 Kondisi Pompa
3 Tekanan air 4 Bar
4 Ampere Name plate
5 Kondisi Panel Electric Pump
6 Kondisi Valve isap
7 Kondisi Valve Discharged
8 Test Run
9 Running ampere R....S....T
10 Strainer ( Filter Pipa Isap )
11 Posisi Switch panel ( Manual off auto ) Auto
Transfer Pump 1 (Lt. 9)
1 Kebersihan Electro Pump
2 Kondisi Pompa
3 Tekanan air 4 Bar
4 Ampere Name plate
5 Kondisi Panel Electric Pump
6 Kondisi Valve isap
7 Kondisi Valve Discharged
8 Test Run
9 Running ampere R....S....T
10 Strainer ( Filter Pipa Isap )
11 Posisi Switch panel ( Manual off auto ) Auto
 Kondisi
No. Uraian Standar Keterangan
√ X
Transfer Pump 2 (Lt. 9)
1 Kebersihan Electro Pump
2 Kondisi Pompa
3 Tekanan air 4 Bar
4 Ampere Name plate
5 Kondisi Panel Electric Pump
6 Kondisi Valve isap
7 Kondisi Valve Discharged
8 Test Run
9 Running ampere R....S....T
10 Strainer ( Filter Pipa Isap )
11 Posisi Switch panel ( Manual off auto ) Auto
Transfer Pump 1 (Samping Water Heater)
1 Kebersihan Electro Pump
2 Kondisi Pompa
3 Tekanan air 4 Bar
4 Ampere Name plate
5 Kondisi Panel Electric Pump
6 Kondisi Valve isap
7 Kondisi Valve Discharged
8 Test Run
9 Running ampere R....S....T
10 Strainer ( Filter Pipa Isap )
11 Posisi Switch panel ( Manual off auto ) Auto
Transfer Pump 2 (Samping Water Heater)
1 Kebersihan Electro Pump
2 Kondisi Pompa
3 Tekanan air 4 Bar
4 Ampere Name plate
5 Kondisi Panel Electric Pump
6 Kondisi Valve isap
7 Kondisi Valve Discharged
8 Test Run
9 Running ampere R....S....T
10 Strainer ( Filter Pipa Isap )
 11 Posisi Switch panel ( Manual off auto ) Auto

Catatan :

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NIK.
Form Checklist PDTR
Bulan :
Kondisi
No Uraian Standard Keterangan
√ X
1 ACB Incoming PLN

2 ACB Incoming Genset

3 Change Over Switch

4 ACB Coupler

5 Busbar

Temperatur Busbar (gunakan

6 Infrared Thermometer) 60⁰ C

7 Temperatur Capasitor Bank

60⁰ C
8 Temepratur Conection Busbar
60⁰ C
9 Instrument

10 Switch

11 Push Button

12 Power Factor Controller

13 Kebersihan Internal Panel

14 Kebersihan Ruang Panel

15 Over Voltage Modul

16 Over Current Modul

17 Timer

Catatan :

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NIK.
Form Checklist Bulanan Genset #1 dan #2
Bulan :
Kondisi
No Uraian Standard Keterangan
√ X
Genset #1
1 Volt Battery Genset 27 volt
2 Level Air Radiator
3 Level Oil
4 Kekencangan Kabel Baterai
5 Hourmeter (Jam Kerja)
6 Water separator Primer
7 Water separator Sekunder
8 Kebersihan Genset
9 Kebersihan Filter Udara
10 Kebocoran Pipa Solar
11 Kondisi Tangki Solar Induk
12 Kondisi Tangki Solar Harian
13 Kebersihan Ruangan Genset
14 Kebersihan Kisi Kisi Radiator
Genset #2
1 Volt Battery Genset 27 volt
2 Level Air Radiator
3 Level Oil
4 Kekencangan Kabel Baterai
5 Hourmeter (Jam Kerja)
6 Water separator Primer
7 Water separator Sekunder
8 Kebersihan Genset
9 Kebersihan Filter Udara
10 Kebocoran Pipa Solar
11 Kondisi Tangki Solar Induk
12 Kondisi Tangki Solar Harian
13 Kebersihan Ruangan Genset
14 Kebersihan Kisi Kisi Radiator

Catatan :

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NIK.
Form Checklist Bulanan LPG
Bulan :
Kondisi
No Uraian Standard Keterangan
√ X
1 Manifold

2 Kebocoran Pipa

3 Tekanan

4 Sensor Kebocoran

5 Flowmeter

Catatan :

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NIK.
FORM CHECKLIST EXHAUST FAN
Bulan :
Kondisi
No Uraian Jumlah Keterangan
√ X
Exhaust Fan Toilet
1 Exhaust Fan 1
2 Flexible Duct 4
3 Ducting Exhaust 1
4 Impellar 1
5 Noise 1
Fresh Air AC
1 Fresh Fan 10
2 Ducting 10
3 Noise 10
Fresh Air Tangga Belakang
1 Impeller 1
2 Mounting Bolt 1
3 Electric Motor 1
4 Casing 1
5 Ducting 1
6 Noise 1
Fresh Air Fan Ruang Pompa
1 Impeller 1
2 Mounting Bolt 1
3 Electric Motor 1
4 Casing 1
5 Ducting 1
6 Noise 1
Exhaust Fan Ruang Pompa
1 Impeller 1
2 Mounting Bolt 1
3 Electric Motor 1
4 Casing 1
5 Ducting 1
6 Noise 1
Exhaust Fan Ruang Laundry
1 Impeller 1
2 Mounting Bolt 1
3 Electric Motor 1
4 Casing 1
5 Ducting 1
6 Noise 1
Exhaust Fan Parkir Motor
1 Impeller 1
2 Mounting Bolt 1
3 Electric Motor 1
4 Casing 1
5 Ducting 1
6 Noise 1
Exhaust Fan Genset
1 Impeller 1
2 Mounting Bolt 1
3 Electric Motor 1
4 Casing 1
5 Ducting 1
6 Noise 1
 Kondisi
No Uraian Jumlah Keterangan
√ X
Exhaust Fan PDTR
1 Impeller 1
2 Mounting Bolt 1
3 Electric Motor 1
4 Casing 1
5 Ducting 1
6 Noise 1
Exhaust Fan Trafo
1 Impeller 1
2 Mounting Bolt 1
3 Electric Motor 1
4 Casing 1
5 Ducting 1
6 Noise 1
Exhaust Fan IPAL
1 Impeller 3
2 Mounting Bolt 3
3 Electric Motor 3
4 Casing 3
5 Ducting 3
6 Noise 3

Catatan :

dicek oleh

(_________________)
NIK.