thy PEMERINTAH KOTA MALANG DINAS KESEHATAN J}. Simp. Laksda Adi Sucipto No. 45 Malang Telp. (0341) 406878 Fax. (0341) 406879 FORMULIR PENILAIAN RUMAH SEHAT Aa ee | ew [mn 5-1 Summ uf 2 cums Rehoon 32 rationA._DATAUMUM WORK Dew Kove Sana Pemilik Sarana_ ‘Alamat Tanggal Kunjungan ‘BETS OF OF OF OF C205 | gata, Sagrean'd Cote en 970, gang 3 ib- 01-2023 KUALITAS FISIK AIR Ya ‘Keruh Berbau Berasa ‘Berwama Hasil berdasarkan (pengamstan/pengujian) Beri tanda ( ¥) pada kolom “Ya” atau “Tidak” Sen-|pfwauna] Bila basil pengamatan jawaban “Ya”, maka, salah sam parameter atau lebih kualitas fisik air memenuhi masuk kategori AT. DATA KHUSUS PENILAIAN RISIKO. ‘Apakal sur gal ida inn Keep air minimal 3 mete dan permilaan nah? Apa aur gal dae ar or sumur- 80 em dan tidak rea? KISS} s Apalat lay id sekelilingsumur gal ida kedap air dan lebar kurang da Tm op el-[s -Apolah dak ada sluren pembumgan at yang balk? selingga ada emangkinan ‘pal al dan eer pda stra dialer ana, Apakah suru gli dak menpuiyal pemimupeehingsa Louvan Ua ask ke Glam amar? ‘mencemari sir sumue? ‘Sotiah eda sumber pencemaran (Cesapan septic tank, torn hewaa,sampal imbah) dengan jaa 8 | Tidak dilengkapi pagar pelindung NKKe JUMEAN ‘Risiko Kontaminaal > ‘Riso Amat Tinggi (AT), blajumlah jawaben * Ya"> 75%, ‘Risto Tingg (1) bila umdah jawaban " Ye" $1 -75% Risiko Sedang (8), bla jumlah jawaban " Ya" 25-50% Risiko Rendah (R), tls jumlah jawaban * Ya" <25% D. 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