Project Name : PONDASI MESIN LINE 2

: NGORO IDUSTIRAL PARK - MOJOKERRTO

Project No. :
Main Contractor : PT. DVACAKRA CENTRICA INDONESIA
Sub-Contractor : Date :
Project Owner : PT. RIGID MAJU BERSAMA Report No. :
Document No. : Page :

INSPECTION CHECKLIST
Equipment Description : Endorsement By : Legend
CIVIL
H : Hold Point A : Document Approval M : Monitoring
Equipment No. : Certification Completion Date : W : 100% Witness R : Document Review P : Perform / Prepare
SW : Spot/Random Witness V : Document / Data Verification I : Information

ACCEPTANCE CRITERIA Responsibility

No DESCRIPTION INSPECTION METHOD REMARKS
(Y/N) Owner Maincont XX XX XX
1 CONCRETE
1,1 Pekerjaan Tulangan
a Kesesuaian bahan dengan standar Visual
b Kondisi penyimpanan (untuk mencegah Visual
korosi & deformasi)
c Pekerjaan Bending besi Visual
d Pembersihan permukaan Visual
e Lokasi, kemiringan, ukuran, jumlah, Visual and Report
pembersihan, dan jarak bar
f Panjang dan lokasi sambungan Visual
g Kekakuan rakitan besi tulangan untuk menahan Visual
penuangan beton

1,2 Pekerjaan Beton

a Kualitas, kuantitas dan kesesuaian semen Visual and report READYMIX
dengan standar yang berlaku MERAK JAYA BETON
b Kualitas dan kuantitas agregat (uji saringan dll) Visual and report READYMIX MERAK JAYA BETON
c Kondisi penyimpanan semen dan agregat Visual READYMIX MERAK JAYA BETON
d Proporsi pencampuran (termasuk bahan tambahan) Report READYMIX MERAK JAYA BETON
e Penggunaan campuran (dengan dukungan Report READYMIX
data teknis) MERAK JAYA BETON
f Form work Report / Visual Plywood 15mm & Pas Bata
g Anchor bolt Visual
h Pembersihan sebelum pengecoran beton Visual
 Project Name : PONDASI MESIN LINE 2
: NGORO IDUSTIRAL PARK - MOJOKERRTO
Project No. :
Main Contractor : PT. DVACAKRA CENTRICA INDONESIA
Sub-Contractor : Date :
Project Owner : PT. RIGID MAJU BERSAMA Report No. :
Document No. : Page :

INSPECTION CHECKLIST
Equipment Description : Endorsement By : Legend
CIVIL
H : Hold Point A : Document Approval M : Monitoring
Equipment No. : Certification Completion Date : W : 100% Witness R : Document Review P : Perform / Prepare
SW : Spot/Random Witness V : Document / Data Verification I : Information

ACCEPTANCE CRITERIA Responsibility

No DESCRIPTION INSPECTION METHOD REMARKS
(Y/N) Owner Maincont XX XX XX
i Persiapan penempatan (konstruksi, peralatan, Visual
perkakas, tenaga kerja, akses)
j Suhu dan kandungan udara beton Report
k Lokasi sambungan konstruksi Report / Visual
m Pengerjaan penempatan dan konsolidasi (tinggi Visual
jatuh, ketebalan lapisan, vibro per getaran)
n Finishing Beton Visual
o Curing (periode, metode pencegahan hilangnya Visual
kelembaban
p Appearance of surface after form removal Report / Visual
(segresi, porositas, crack, etc)
q Finishing Mortar (lecel, champher, crack, Visual
Preparasi, dll)
r Uji beton (kemerosotan, kuat tekan, penyimpanan, Report / Visual
konduksi kubus uji)

Prepared by, Witnessed/Reviewed by, Reviewed & Approved by,

(sub contractor name)

Print name Date Print name Date Print name Date