Security Level 2

B G - 06 22 1 I D

ISSUED AUG.19,’21

BUSINESS GUIDE

EQUIPMENT & TOOLS INSPECTIONS

 When handling any PDF or hard copy of this standard, users shall confirm they are the
latest version. Iindicate e-file name in Arial 10p.
Already set the field code
 In case editablePlease
filesupdate
are customized
the file name for JOB specific requirements, sufficient
by Right-
attention shall clicking.
be paid to prevent inappropriate changes.
 This is intellectual property of IKPT and whole or any part of the standard, in any form or
way without permission, cannot be reproduced, disclosed to the third party or used not for the
original purpose of providing information.

PT INTI KARYA PERSADA TEHNIK

BG-06221ID.doc
 Security Level 2

BG-06221ID
EQUIPMENT & TOOLS INSPECTIONS ISSUED AUG.19,’21
PAGE 1 OF 4

CONTENTS

1. GENERAL 2
1.1 Objectives 2
1.2 Scope 2
1.3 Terms and Definations 2
1.4 References 2

2. ROLE AND RESPONSIBILITY 2

2.1 IKPT 2
2.2 Subcontractor 2

3. TYPES OF INSPECTIONS AND PROCEDURES 3

3.1 Equipment inspection 3
3.2 Tools inspection 4

4. VERIFYING DOCUMENTS 4

Appendix (1) Inspection & Testing Responsibility Matrix (P.1/5~P.5/5)

Appendix (2) Inspection Form (P.1/89~P.89/89)

History (P.1/1)

BG-06221ID.doc
 Security Level 2

BG-06221ID
EQUIPMENT & TOOLS INSPECTIONS ISSUED AUG.19,’21
PAGE 2 OF 4

1. GENERAL

1.1 Objectives

The primary purpose of this document is to provide requirement for types, method and frequency of inspection on
construction equipment & tools being utilized by IKPT.

1.2 Scope

This procedure shall be applied by IKPT, and all subcontractors work for IKPT.

1.3 Terms and Definations

The term “Equipment and Tools” used in this procedure is covering all construction equipment, i.e.: lifting /
rigging equipment, pile driving machine, soil handling equipment, electric motor equipment, welding equipment,
scaffolding, etc.

1.4 References

BG-06200ID, SHE REGULATION AND STANDARD

2. ROLE AND RESPONSIBILITY

2.1 IKPT
(1) IKPT inspectors shall monitor and confirm the status and reports of Carry-In Inspection, Daily Inspection,
and quarterly inspection conducted by Subcontractors.
(2) IKPT inspectors shall at their discretion conduct visual or functional check.
(3) IKPT inspectors and/or other related discipline supervisors shall always observe equipment and tools in the
construction premises by daily surveillance.
In case that any unsafe condition is observed, such as missing or breakage of safety devices, or
infringement of the requirements of this procedure, such as a missing safety tag, validity date, etc., the
Inspectors shall inform the Subcontractors both verbally and by written notice to remedy, replace or remove
the subject equipment or tools.
(4) IKPT SHE Manager and his staff shall have the right to review, monitor and inspect Subcontractor’s
Equipment/Tools Logbooks. Inspection will be done based on Inspection & Testing Responsibility Matrix
and form.
(5) IKPT FM, CM and Construction personnel ensure all over tools and equipment in his/her area are
proper/operable condition and have possesses all legal requirement.

2.2 Subcontractor
(1) Subcontractors shall provide their workers with efficient and reliable construction equipment and tools, and
always maintain them in safe and operable condition.
IKPT inspection or instructions will not relieve the Subcontractors of their full responsibility and liability.
(2) Subcontractors shall assign competent person to inspect construction equipment and tools, and organize a
maintenance group to keep them in safe and operable condition through the entire construction period.
(3) Subcontractors shall conduct carry-in inspection, daily inspection and regular maintenance in accordance
with the requirements and use the attached daily Checklist.
(4) In any case subcontractor shall satisfy them self that the construction equipment’s especially heavy and
lifting equipment are operable in safe and proper condition prior to mobilization to Site, by conducting own
pre-mob inspection.

BG-06221ID.doc
 Security Level 2

BG-06221ID.doc
 Security Level 2

BG-06221ID
EQUIPMENT & TOOLS INSPECTIONS ISSUED AUG.19,’21
PAGE 3 OF 4

(5) Subcontractor shall not modify or remedy their equipment/tools without Manufacturer and/or IKPT
agreement.
(6) Subcontractors shall maintain historical inspection records of each equipment and tools.
(7) Subcontractor shall furnish Operation and Maintenance Manuals provided by Manufacturers and submit
them to IKPT
(8) For major and vital equipment, such as mobile cranes, gondolas, etc., Subcontractors shall furnish
Certifications for Manufacturing and Operation issued by Authorities in accordance with Government
Regulations and submits them to IKPT

3. TYPES OF INSPECTIONS AND PROCEDURES

Any deficiencies noted on the report shall be addressed. If the deficiency affects the safe operation of the
equipment and tools, the equipment / tools shall be shut down and tagged detective until corrective action is
completed.
Deficiencies corrected shall be documented on the inspection report that noted the deficiency along with signature
of inspection.
A copy of the most recent inspection report shall be maintained on each piece of equipment by the subcontractor.

Responsibility matrix for construction equipment and tools inspection & testing are as depicted on Appendix (1)

3.1 Equipment inspection

Followings are minimum inspection which shall be conducted by subcontractor before inspecting by IKPT.
3.1.1 Carry-In Inspection

Carry-In inspection shall be done to ensure that the equipment are in safe condition, operable and have possesses
all legal requirement.
This is a pre-requisite inspection prior to the equipment utilization at the construction site.
(1) Subcontractors shall perform an inspection and test and provide a valid Operating permit from the
Government as required.
(2) Inspection and check items shall be prepared by IKPT and at least shall follow manufacturer
recommendations.
(3) IKPT inspectors shall satisfy them self that the equipment are operable and in a safe condition by reviewing
the validity of all legal document, visual check and witnessing the functional test as necessary.
(4) Safety Tagging system shall be applied when the inspection and testing has been satisfactorily completed.

3.1.2 Pre-Use / daily Inspection

Prior to daily use, the Pre-use Inspection for equipment shall be carried out by the equipment operator.
Inspection items are consisting of but not limited to:

(1) Safety Guards

Safety covers for rotating or moving parts, warning lamps or alarm, etc.
(2) Safety Control Devices
Over-load indicator, over-wind preventive devices, pressure control valves, emergency stopping devices,
brakes, etc.
(3) Critical Parts
Sling wires, web slings, chains, shackles, or parts, which are apt to be defected or abraded, etc.
(4) Daily check list
Equipment operator will conduct the daily check based on daily check list ass listed on this procedure and
approved by subcontractor equipment supervisor.
BG-06221ID.doc
 Security Level 2

BG-06221ID.doc
 Security Level 2

BG-06221ID
EQUIPMENT & TOOLS INSPECTIONS ISSUED AUG.19,’21
PAGE 4 OF 4

3.1.3 Monthly or Quarterly Inspection

A through inspection to ensure that the equipment is operable in safe and proper condition
(1) The inspection shall be conducted by IKPT Safety.
(2) The inspection check items shall conform to Manufacturer’s recommendation. It’s shall minimum included
those daily / pre-use inspection items, but not limited to structural defect, excessive wear and hydraulics or
air leak.
(3) Inspection report will be reported to subcontractor to make rectify the finding.
(4) Safety Tagging system and sticker system shall be applied when the inspection and testing has been
satisfactorily completed.
3.1.4 Additional inspection and testing
An additional inspection and testing may be done on a specific part of the equipment when there is evidence of
physical damage or after the part has been repaired or altered.
In case of major alteration or alteration to the part which have direct bearing to the safety of the equipment,
subcontractor shall obtain recommendations from the equipment manufacturer

3.2 Tools inspection

3.2.1. Carry-In Inspection

Carry-In inspection shall be done by IKPT to ensure that the tools are operable in safe condition. This is a pre-
requisite inspection prior to the tools utilization at the construction site. At their discretion, IKPT SHE inspectors
may witness the inspection and testing. A Safety tagging system by IKPT SHE shall be applied once the tools have
passed the inspection.

3.2.2. Pre use / daily inspection

(1) This inspection shall be done every time before the tools are being utilize.
(2) Inspection shall be performed by the user or the group supervisor.
(3) Inspection and check item shall be but not limited to the followings:
 Safety guard condition.
 Visual inspect on any evidence of physical damage and or corroded part (especially on electrical cord)

4. VERIFYING DOCUMENTS
Inspection & test record

BG-06221ID.doc
 Security Level 2
BG-06221ID
Appendix (1)-1/5

Inspection & testing responsibility matrix

No Equipment and tools Form Number Activity Sub-contractor IKPT

1 Lifting Equipment 1. Carry In inspection

Documentation
 Crane Lattice Boom  Form -I-001
 Legal aspect (SIO, equipment Provide Review
 Form -I-001A
operating permit)
 Crane Telescopic Boom  Form -I-002 Provide Review
 Log book
 Form -I-002A Provide Review
 Truck mounted crane  Manual book
 Form -I-003 Inspection & testing
 Form -I-003A  Form as per form no. Perform Perform
 forklift
 Form -I-010  Function test (load test, Perform Witness
 Form -I-010A movement test, etc.)
Tagging System Perform

2. Pre-Use/ Daily Inspection

Inspection & testing
 Visual Perform Review
 Function test (limited) Perform Witness

3. Monthly or Quarterly
Inspection
Inspection & testing
 Visual Perform Perform

 Function test
Perform Witness
(movement, engine,
cooling system,
lifting)
Tagging System Perform
2 Lifting Accessories 1. Carry In inspection
Inspection & testing
 Wire Sling  Form -I-004
 Visual Perform Perform
 Webbing sling  Form -I-005
 Shackle  Form -I-006  Function test (Load test, etc.) Perform Witness

Tagging System Perform

 Block and Tackle  Form -I-007
 Chain Block & level block  Form -I-008 2. Pre-Use/Daily Inspection
 Chain sling  Form -I-009  Visual Inspection Perform Review
3 Work at height 1. Carry In inspection
 Manlift  Form -I-021 Documentation
 Form -I-021A  Log book Provide Review
 Gondola  Form -I-022  Manual book Provide Review
Inspection & testing
 Visual Perform Perform

 Function test (load test, Perform Perform/

Witness
movement test, etc.)
BG-06221IDa1.doc
 Security Level 2
BG-06221ID
Appendix (1)-2/5

Inspection & testing responsibility matrix

No Equipment and tools Form Number Activity Sub-contractor IKPT

Tagging System Perform

2. Pre-Use Inspection
Inspection & testing
 Visual Perform Review
 Function test (limited) Perform Witness

3. Monthly/ Quarterly Inspection

Inspection & testing
 Visual Perform Perform
 Function test (movement, Perform Witness

engine, cooling system)

Tagging System Perform

 Scaffolding  Form -I-023 Carry In inspection

 Ladder  Form -I-024 Inspection & testing
 Visual Perform Perform
 Function test (Strength test, Perform Witness

etc.)
Tagging System Perform
2 Concreting Equipment 1. Carry In inspection
 Molen Concrete manual Documentation
 Form -I-030
 Log book Provide Review
 Form -I-030A
 Mixer Truck  Manual book Provide Review
 Form -I-031
Inspection & testing
 Form -I-031A Perform Perform
 Visual
 Form -I-032 Perform Perform/
 Concrete Pump  Function test (load test,
 Form -I-032A Witness
movement test, etc.)
Tagging System Perform

2. Pre-Use Inspection
Inspection & testing
 Visual Perform Review
 Function test (limited) Perform Witness

3. Monthly/ Quarterly
Inspection
Inspection & testing Perform Perform
 Visual
 Function test (movement, Perform Review /
Witness
engine, cooling system)
Tagging System Perform

BG-06221IDa1.doc
 Security Level 2
BG-06221ID
Appendix (1)-3/5

Inspection & testing responsibility matrix

No Equipment and tools Form Number Activity Sub-contractor IKPT

3 Pilling Equipment 1. Carry In inspection

 Pile Driving  Form -I-040 Documentation
 Form -I-040A  Log book Provide Review
 Manual book Provide Review
Inspection & testing
 Visual Perform Perform

 Function test (load test, Perform Perform/

Witness
movement test, etc.)
Tagging System Perform

2. Pre-Use Inspection
Inspection & testing
 Visual Perform Review
 Function test (limited) Perform Witness

3. Quarterly Inspection
Inspection & testing
 Visual Perform Review
 Function test (movement, Perform Review /
Witness
engine, cooling system)
Tagging System Perform

3 Earth Work 1. Carry In inspection

 Bulldozer  Form -I-043 Documentation
 Form -I-043A  Log book Provide Review
 Excavator  Form -I-044  Manual book Provide Review

 Form -I-044A Inspection & testing

 Visual Perform Perform
 Loader  Form -I-045
 Function test (movement test, Perform Witness
 Form -I-045A
etc.)
 Grader  Form -I-046
Tagging System Perform
 Form -I-046A
2. Pre-Use Inspection
 Vibrator Roller  Form -I-047
Inspection & testing
 Form -I-047A  Visual Perform Review
 Power Shovel  Form -I-048  Function test (limited) Perform Review
 Form -I-048A 3. Monthly/ Quarterly Inspection
 Drag line/clamshell  Form -I-049 Inspection & testing
 Form -I-049A  Visual Perform Review
 Function test (movement, Perform Review /
Witness
engine, cooling system)
Tagging System Perform

BG-06221IDa1.doc
 Security Level 2
BG-06221ID
Appendix (1)-4/5

Inspection & testing responsibility matrix

No Equipment and tools Form Number Activity Sub-contractor IKPT

4 Vehicle 1. Carry In inspection

 Lorry and Common Truck  Form -I-051 Documentation
 Form -I-051A  Legal aspect (SIO, Provide Review
 Dump Truck  Form -I-052 equipment operating permit)
 Form -I-052A  Log book Provide Review
 Ambulance  Form -I-053  Manual book Provide Review

 Form -I-053A Inspection & testing

 Visual Perform Perform
 Common Vehicle  Form -I-054
 Function test (load test, Perform Witness
 Form -I-054A
movement test, etc.)
 Trailer Truck  Form -I-055
Tagging System Perform
 Form -I-055A
2. Pre-Use Inspection
Inspection & testing
 Visual Perform Review
 Function test (limited) Perform Witness

3. Monthly/ Quarterly Inspection

Inspection & testing
 Visual Perform Review
 Function test (movement, Perform Review /
Witness
engine, cooling system)
Tagging System Perform

5 Diesel Equipment 1. Carry In inspection

 Compressor/Gen-set/Water  Form -I-060 Documentation
Jet  Form -I-060A  Log book Provide Review
 Welding Machine  Form -I-062  Manual book Provide Review

 Form -I-062A Inspection & testing

 Visual
 Function test (load test, Perform Perform
Perform Witness
movement test, etc.)
Tagging System Perform

2. Pre-Use Inspection
Inspection & testing Perform Review
 Visual
 Function test (limited) Perform Review

3. Monthly/ Quarterly
Inspection
Inspection & testing Perform Review
 Visual

BG-06221IDa1.doc
 Security Level 2
BG-06221ID
Appendix (1)-5/5

Inspection & testing responsibility matrix

No Equipment and tools Form Number Activity Sub-contractor IKPT

 Function test (movement, Perform Review /

Witness
engine, cooling system)
Tagging System Perform

6 Electrical Equipment / Tool 1. Carry In inspection

 Electrical panel and  Form -I-061 Inspection & testing
Appliance  Visual Perform Perform
 Electrical air compressor  Form -I-063  Function test Perform Witness

 Chain Saw  Form -I-064 Tagging System Perform

 Grinding  Form -I-065

 Hand Drill  Form-I-066 2. Pre-Use Inspection
Inspection & testing
 Cut off Machine  Form -I-067
 Visual Perform Review
 Electrical Lighting  Form -I-068
 Function test (limited) Perform Witness
 Electrical Accessories  Form -I-069
 Welding Transformer  Form -I-070
 Welding Rod dryer  Form -I-071
 Winch  Form -I-072
 Motor hoist  Form -I-073

6 Safety Equipment and tools 1. Carry In inspection

 Safety Harness  Form -I-081
 Visual Inspection Perform Witness
 Fire Extinguisher  Form -I-082

2. Quarterly Inspection
 Visual Inspection Perform Review
 Tagging System Perform
7 Others 1. Carry In inspection
 Stamper  Form -I-090 Inspection & testing
 Cutting torch  Form -I-091  Visual Perform Perform
 Manual hydraulic  Form -I-092  Function test Perform Witness

Tagging System Perform

2. Pre-Use Inspection
Inspection & testing Perform Review
 Visual
 Function test (limited) Perform Witness

BG-06221IDa1.doc
 Security Level 2
BG-06221ID
Appendix (2)-1/89

INSPECTION FORM

Form-I-001 Crane Lattice Boom Form

Form-I-001A Crane Lattice Boom Daily
Form Form-I-002 Crane Telescopic Boom Form
Form-I-002A Crane Telescopic Boom Daily
Form Form-I-003 Truck Mounted Crane Form
Form-I-003A Truck Mounted Crane Daily Form
Form-I-004 Wire Sling Form
Form-I-005 Webbing Sling Form
Form-I-006 Shackle Form
Form-I-007 Block & Tackle Form
Form-I-008 Chain Block & Level Block
Form Form-I-009 Chain Sling Form
Form-I-010 Forklift Form
Form-I-010A Forklift daily Form
Form-I-021 Manlift Form
Form-I-021A A Manlift daily Form
Form-I-022 Gondola form
Form-I-023 Scaffolding Form
Form-I-024 Ladder Form
Form-I-030 Molen concrete manual Form
Form-I-031 Mixer Truck Form
Form-I-031A Mixer Truck Daily Form
Form-I-032 Concrete Pump Form
Form-I-032A Concrete Pump Daily Form
Form-I-040 Pile Driving Form
Form-I-040A A Pile Driving Daily Form
Form-I-043 Bulldozer Form
Form-I-043A Bulldozer Daily Form
Form-I-044 Excavator Form
Form-I-044A Excavator Daily Form
Form-I-045 Loadder Form
Form-I-045A Loadder Daily Form
Form-I-046 Grader Form
Form-I-046A Grader Daily Form
Form-I-047 Vibro Roller Form
Form-I-047A Vibro Roller Daily Form
Form-I-048 Power Shovel Form
Form-I-048A Power Shovel Daily Form
Form-I-049 Drag line -clamshell Form
Form-I-049A Drag line -clamshell Daily Form
Form-I-051 Lorry and Common Truck Form
Form-I-051A Lorry and Common Truck Daily
Form Form-I-052 Dump Truck Form
Form-I-052A Dump Truck Daily Form
Form-I-053 Ambulance Form
Form-I-053A Ambulance Daily Form
Form-I-054 Common Vehicle Form
Form-I-054A Common Vehicle Daily Form
Form-I-055 Trailler Truck Form
Form-I-055A Trailler Truck Daily Form
Form-I-060 Compressor, Gen-set, Water jet Form
Form-I-060A Compressor, Gen-set, Water jet Daily Form
Form-I-061 Electrical Panel and Appliance Form
Form-I-062 Welding Machine Form
Form-I-062A Welding Machine Daily Form
Form-I-063 Electric Air Compressor Form
Form-I-064 Chain Saw Form
Form-I-065 Grinding Form

BG-06221IDa2.doc
 Security Level 2
BG-06221ID
Appendix (2)-2/89

Form-I-066 Hand Drill Form

Form-I-067 Cut-off machine form
Form-I-068 Electrical Lighting Form
Form-I-069 Electrical Accesories Form
Form-I-070 Welding Trafo Form
Form-I-071 Welding Rod Dryer Form
Form-I-072 Winch Form
Form-I-073 Motor Hoist Form revised
Form-I-081 Safety Harness Form
Form-I-082 Fire Extinguisher Form
Form-I-090 Stamper Form
Form-I-091 Cutting Torch Form
Form-I-092 Manual Hydraulic Form

BG-06221IDa2.doc
 Security Level 2
BG-06221ID
3
Appendix (2)- /89
Form no: Form-I-001

TRUCK/MOBILE CRANE LATTICE BOOM

Inspection Date :
Location of Inspection :

INSPECTION STANDARD Company/Subcontractor :

Validty of inspection :
(PER.08/MEN/2020 PESAWAT ANGKAT DAN PESAWAT ANGKUT) Type of inspection : Monthly for High Risk/ every 3 Months
This form must be completed by the operator and company user before entering the equipment to site project and to be operated. All equipment conditon must meet to the safety regulation, government regulation and IKPT
SHES Plan.
EQUIPMENT CARRY-IN / RE-INSPECTION CERTIFICATE
Type: Police No:
Machine/Engine No: Certificate (STNK) No:
Serial/Plate/Body No.: Certifcate Validity:
Manufacture /Year: Validity Vehicle test by Government (KIR):
Lifting manufacture /Year: Equip. Operation license (SILO/SIA) no.:
Capacity: Equip. Operation license (SILO/SIA) Validity:
Serial Lifting No: Operator Name:
ID No: Operator License (SIO) No. :
Operator license (SIO) Validity:
INSPECTION METHOD INSPECTION RESULT
No INSPECTION ITEM STANDARDS REASON FOR NOT COMPLY
VISUAL FUNCTION IKPT CLIENT
Common
1 Maintenance record For the pass year is available ●
2 Daily check list For the pass 3 months is available ●
3 Main Engine (mesin utama) No abnormal noise,no Leak, easy for start and off, no spark (Tidak
berisik, bocor,mudah di hidup dan matikan, tidak ada percikan api) ● ●

4 Engine starting Easy for start and stop (mudah untuk dinyalakan dan matikan) ●
5 Battery ( Accu ) Have cover by isolator material ex. Rubber,hard plastic( memiliki
●
peutup dari material isolator ex. Karet, plastik yg keras)
6 Fuel tank cover Tight and lock (rapat dan terkunci) ●
7 Radiator No leak (tidak bocor) ●
8 Horn (klakson) Work properly (berfungsi dengan baik) ●
9 Exhaust system (sistem No leak, flame arrestor available and comply with IKPT standard
buangan/knalpot) (tidak bocor, terdapat flam arrestor dan sesuai dengan standart IKPT) ● ●

10 Fuel system ( sistem bahan bakar) No leak (tidak bocor) ●

11 Rear view mirrors (kaca spion) As manufacturing standard (sesuai dengan standar pabrikan) ●
12 Windshied wipers Work properly (berfungsi dengan baik) ● `
13 Turning lights ( lampu sein) Work properly (berfungsi dengan baik) ●
14 Stop lights (lampu stop) Work properly (berfungsi dengan baik) ●
15 Rotary Lamp Work properly (berfungsi dengan baik)
16 Reverse lamp and sign (lampu Work properly (berfungsi dengan baik)
mundur dan bel) ● ●
17 Break system (sistem pengereman) Work properly (berfungsi dengan baik) ●
18 Test all function system Work properly for all device (semuanya berfungsi dengan baik)
(Electrical/hydrolic) ●

19 Back Mirror Work properly (berfungsi dengan baik) ●

20 Each Side of Windows glasses No crack and clear (tidak retak dan tidak buram) ●
21 Tire or Crawler No crack, recondition, no bare (tidak retak,rekondisi, tidakgundul)
●
22 Fire Extinguisher Fire extinguisher have to install inside cabine operator ( Apar harus
●
tersedia di dalam ruangan operator )
23 Firest Aid box Available (ada) ●
Special Requirement
1 Panel Instrument indicator work properly (berfungsi dengan baik) ●
2 Safety lutch Available and work properly (ada, berfungsi dengan baik ) ● ●
3 Anti two block Available and work properly (ada, berfungsi dengan baik ) ●
4 *Load indicator ( Alarm sound, Available and work properly (ada, berfungsi dengan baik )
external ●
5 *Load moment indicator ( Cut off Available and work properly (ada, berfungsi dengan baik )
engine) ●

6 Manual load chart Available and clearly (ada, jelas) ●

7 Manual radius boom Available and clearly (ada, jelas) ●
8 Main hook block ( Hook utama ) No crack,work properly,grease (tidak retak,berfungsi dengan
baik,terlumasi) ●
9 Main load hoist ( beban penggerak No broke of wire sheet , greased, No connection (tidak putus pada
● ●
utama ) wiring,terlumasi, tidak sambungan)
10 boom No bent, rusty and work properly (tidak bengkok, karatan dan
berfungsi dengan baik) ●

11 Lift cylinder Work properly (berfungsi dengan baik) ●

12 Boom pivoting Available,No crack,work properly (ada,tidak retak,berfungsi dengan
●
baik)
13 Main load drum Work properly (berfungsi dengan baik) ●
14 Auxilary load drum Work properly (berfungsi dengan baik) ● `
15 Wire Sling No corrotion, crack, no broken (tidak berkarat, retak, putus) ● `
16 Cabin operator assy Clean, no oil spill (bersih,tidak ada tumpahan minyak) ●
17 Boom rest No crack and work properly (tidak retak dan berfungsi dengan baik)
● ●
18 Driver cabin assy Clean, no oil spill (bersih,tidak ada tumpahan minyak) ●
19 Truck or lower engine No noise,Leak, easy for start and off, no spark ( Tidak
●
berisik,bocor,mudah di hidup dan matikan, tidak ada percikan api)
20 Air cleaner assy No leak (tidak bocor) ●
21 Counter weight assy Available,tight and no crack (ada,rapat dan tidak retak) ● ●
22 Front outrigger jacks No leak, work properly (tidak bocor, berfungsi dengan baik) ● ●
23 Rear outrigger jacks No leak, work properly (tidak bocor, berfungsi dengan baik) ● ●
24 Drive or rear wheels No crack,recondition,bare (tidak retak,rekondisi,gundul) ●
25 Turn table Work properly (berfungsi dengan baik) ●
26 Hydraulic tank assy No leak,level normal condition >40% (tidak bocor,level normal
● ●
>40%)
27 Hydroulic system (sistem hidrolik) No Corrotion, no leak,work and smothly (tidak berkarat, tidak
bocor,berfungsi dan lancar) ● ●

BG-06221IDa2.xlsx
 Security Level 2
BG-06221ID
Appendix (2)- /894
Form no: Form-I-001

TRUCK/MOBILE CRANE LATTICE BOOM

Inspection Date :
Location of Inspection :
Company/Subcontractor :
INSPECTION STANDARD Validty of inspection :
Type of inspection : Monthly for High Risk/ every 3 Months
(PER.08/MEN/2020 PESAWAT ANGKAT DAN PESAWAT ANGKUT)
This form must be completed by the operator and company user before entering the equipment to site project and to be operated. All equipment conditon must meet to the safety regulation, government regulation and IKPT
SHES Plan.

INSPECTION STATUS
PASSED

HOLD

REJECTED

SPECIAL NOTE FROM CLIENT:

INSPECTION BY APPROVED BY

Name and Signature Name and Signature

Stiker Number

Stiker Number

Stiker Number

BG-06221IDa2.xlsx
 Security Level 2
BG-06221ID
5
Appendix (2)- /89
Form no: Form-I-001A
Inspection Date :
TRUCK/MOBILE CRANE LATTICE BOOM Location of Inspection :
Company/Subcontractor :
DAILY CHECK LIST Validty of inspection :
ID No :
(PER.08/MEN/2020 PESAWAT ANGKAT DAN PESAWAT ANGKUT)
This form must be completed by the Operator and Leader user before equipment to be operated. All equipment conditon must meet to the safety regulation, government regulation and IKPT SHES Plan.
Period: / / to / /
No INSPECTION ITEM STANDARDS REASON FOR NOT COMPLY
Senin Selasa Rabu kamis Jumat Sabtu Minggu
1 Battery ( Accu ) liquid level/indicator green (tinggi air atau warna indicator hijau)

2 Fuel tank cover Tight and lock (rapat dan terkunci)

3 Radiator No leak (tidak bocor)
4 Horn (klakson) Work properly (berfungsi dengan baik)
5 Fuel system ( sistem bahan bakar) No leak (tidak bocor)
6 Rear view mirrors (kaca spion) Work properly (berfungsi dengan baik)
7 Windshied wipers Work properly (berfungsi dengan baik) `
8 Turning lights ( lampu sein) Work properly (berfungsi dengan baik)
9 Stop lights (lampu stop) Work properly (berfungsi dengan baik)
10 Rotary Lamp Work properly (berfungsi dengan baik)
11 Reverse lamp and sign (lampu Work properly (berfungsi dengan baik)
mundur dan bel)
12 Break system (sistem pengereman) Work properly (berfungsi dengan baik)
13 Test all function work properly for all device (semuanya berfungsi dengan baik)
system
(Electrical/hydrolic)
14 Back Mirror Work properly (berfungsi dengan baik)
15 Tire or Crawler No crack, no bare (tidak retak, tidagundul)
16 Fire Extinguisher Available (ada)
17 Firest Aid box Available (ada)
18 Panel Instrument indicator Work properly (berfungsi dengan baik )

19 Safety lutch Work properly (berfungsi dengan baik )

20 Anti two block Work properly (berfungsi dengan baik )
21 *Load indicator ( Alarm sound, Work properly (berfungsi dengan baik )
external
22 *Load moment indicator ( Cut Work properly (berfungsi dengan baik )
off engine)
23 Main hook block ( Hook utama ) No crack,work properly,grease (tidak retak,berfungsi dengan
baik,terlumasi)
24 Main load hoist ( beban penggerak No broke of wire , greased (tidak putus pada wiring ,terlumasi)
utama )
25 boom No bent and work properly (tidak bengkok dan berfungsi dengan
baik)
26 Lift cylinder Work properly (berfungsi dengan baik)
27 Boom pivoting No crack,work properly (tidak retak,berfungsi dengan baik)
28 Main load drum Work properly (berfungsi dengan baik)
29 Auxilary load drum Work properly (berfungsi dengan baik) `
30 Wire Sling No crack, no broken (tidak berkarat, tidak retak, putus) `
31 Cabin operator assy Clean, no oil spill (bersih,tidak ada tumpahan minyak)
32 Boom rest No crack and work properly (tidak retak dan berfungsi dengan
baik)
33 Driver cabin assy Clean, no oil spill (bersih,tidak ada tumpahan minyak)
34 Truck or lower engine No noise,Leak, easy for start and off, no spark ( Tidak
berisik,bocor,mudah di hidup dan matikan, tidak ada percikan api)
35 Air cleaner assy No leak (tidak bocor)
36 Counter weight assy Tight and no crack (rapat dan tidak retak)
37 Front outrigger jacks No leak, work properly (tidak bocor, berfungsi dengan baik)
38 Rear outrigger jacks No leak, work properly (tidak bocor, berfungsi dengan baik)
39 Drive or rear wheels No crack,bare (tidak retak, gundul)
40 Turn table Work properly (berfungsi dengan baik)
41 Hydraulic tank assy No leak,level normal condition >40% (tidak bocor,level normal
>40%)
42 Hydroulic system (sistem hidrolik) No leak,work and smothly (tidak bocor,berfungsi dan lancar)

OPERATOR
SIGNED BY
LEADER

REMARKS

BG-06221IDa2.xlsx
 Security Level 2
BG-06221ID
6
Appendix (2)- /89
Form no: Form-I-002

Inspection Date :
TRUCK/MOBILE CRANE TELESCOPIC BOOM Location of Inspection :
Company/Subcontractor :
INSPECTION STANDARD Validty of inspection :

(PER.08/MEN/2020 PESAWAT ANGKAT DAN PESAWAT ANGKUT) Type of inspection : Monthly for High Risk/ every 3 Months
This form must be completed by the operator and company user before entering the equipment to site project and to be operated. All equipment conditon must meet to the safety regulation, government regulation and IKPT
SHES Plan.
EQUIPMENT CARRY-IN / RE-INSPECTION CERTIFICATE
Type: Police No:
Machine/Engine No: Certificate (STNK) No:
Serial/Plate/Body No.: Certifcate Validity:
Manufacture / Year: Validity Vehicle test by Government (KIR):
Lifting manufacture / Year: Equip. Operation license (SILO/SIA) no.:
Capacity: Equip. Operation license (SILO/SIA) Validity:
Serial Lifting No: Operator Name:
ID No: Operator License (SIO) No. :
Operator license (SIO) Validity:
INSPECTION METHOD INSPECTION RESULT
No INSPECTION ITEM STANDARDS REASON FOR NOT COMPLY
VISUAL FUNCTION IKPT CLIENT
Common
1 Maintenance record For the pass year is available ●
2 Daily check list For the pass 3 months is available ●
3 Main Engine (mesin utama) No abnormal noise,no Leak, easy for start and off, no spark (Tidak
berisik, bocor,mudah di hidup dan matikan, tidak ada percikan api) ● ●

4 Engine starting Easy for start and stop (mudah untuk dinyalakan dan matikan) ●
5 Battery ( Accu ) Have cover by isolator material ex. Rubber,hard plastic (memiliki
peutup dari material isolator ex. Karet, plastik yg keras) ●

6 Fuel tank cover Tight and lock (rapat dan terkunci) ●

7 Radiator No leak (tidak bocor) ●
8 Horn (klakson) Work properly (berfungsi dengan baik) ●
9 Exhaust system (sistem No leak, flame arrestor available and comply with CAP standard(
● ●
buangan/knalpot) tidak
10 Fuel system ( sistem bahan bakar) No leak (tidak bocor) ●
11 Rear view mirrors (kaca spion) as manufacturing standard (sesuai dengan standar pabrikan) ●
12 Windshied wipers Work properly (berfungsi dengan baik) ● `
13 Turning lights ( lampu sein) Work properly (berfungsi dengan baik) ●
14 Stop lights (lampu stop) Work properly (berfungsi dengan baik) ●
15 Rotary Lamp Work properly (berfungsi dengan baik)
16 Reverse lamp and sign (lampu Work properly (berfungsi dengan baik)
mundur dan bel) ● ●
17 Break system (sistem pengereman) Work properly (berfungsi dengan baik) ●
18 Test all function system Work properly for all device (semuanya berfungsi dengan baik)
(Electrical/hydrolic) ●

19 Back Mirror Work properly (berfungsi dengan baik) ●

20 Each Side of Windows glasses No crack and clear (tidak retak dan tidak buram) ●
21 Tire or Crawler No crack, recondition, bare (tidak retak,rekondisi,gundul) ●
22 Fire Extinguisher Fire extinguisher have to install inside cabine operator ( Apar harus
●
tersedia di dalam ruangan operator )
23 First Aid Box Avilable (ada) ●
Special Requirement
1 Flame arrestor Available and comply with IKPT standard (terpasang dan sesuai
●
dengan standard IKPT)
2 Power take off ( PTO ) < 100 T PTO have to function if Crane up to 100 Ton ( PTO harus berfungsi
untuk crane dibawah 100 Ton ) ● ●
3 Panel Instrument indicator Work properly (berfungsi dengan baik) ●
4 Safety lutch Available, work properly ( ada, berfungsi dengan baik) ● ●
5 Anti two block Available, work properly ( ada, berfungsi dengan baik) ●
6 *Load indicator ( Alarm sound, Available, work properly ( ada, berfungsi dengan baik)
external ●
7 *Load moment indicator ( Cut off Available and work properly (ada, berfungsi dengan baik )
engine) ●

8 Manual load chart Available and clearly (ada, jelas) ●

9 Manual radius boom Available and clearly (ada, jelas) ●
10 Main hook block ( Hook utama ) No crack,work properly,grease (tidak retak,berfungsi dengan
baik,terlumasi) ●
11 Main hoist line ( beban penggerak No broke of wire sheet max.2, greased,No connection (tidak putus
● ●
utama ) pada wiring max.2,terlumasi,tidak sambungan)
12 Auxilary Hook Available and installed (ada dan terpasang) ●
13 Auxilary Line Available and installed (ada dan terpasang) ●
14 Tip or upper boom Available and installed (ada dan terpasang) ●
15 Mid boom Work properly (berfungsi dengan baik) ●
16 Base or lower boom Work properly (berfungsi dengan baik) ●
17 Lift cylinder Work properly (berfungsi dengan baik) ●
18 Boom pivoting Available,No crack,work properly (ada,tidak retak,berfungsi dengan
●
baik)
19 Main load drum Work properly (berfungsi dengan baik) ●
20 Auxilary load drum Work properly (berfungsi dengan baik) ● `
21 Wire Sling No rusty, crack, no broken (tidak berkarat, retak, putus) ● `
22 Cabin operator Clean, no oil spill (bersih,tidak ada tumpahan minyak) ●
23 Boom rest No crack and work properly (tidak retak dan berfungsi dengan baik)
● ●
24 Driver cabin assy Clean, no oil spill (bersih,tidak ada tumpahan minyak) ●

BG-06221IDa2.xlsx
 Security Level 2
BG-06221ID
Appendix (2)- /897
Form no: Form-I-002

Inspection Date :
TRUCK/MOBILE CRANE TELESCOPIC BOOM Location of Inspection :
Company/Subcontractor :

INSPECTION STANDARD Validty of inspection :

Type of inspection : Monthly for High Risk/ every 3 Months
(PER.08/MEN/2020 PESAWAT ANGKAT DAN PESAWAT ANGKUT)
This form must be completed by the operator and company user before entering the equipment to site project and to be operated. All equipment conditon must meet to the safety regulation, government regulation and IKPT
SHES Plan.
25 Truck or lower engine No noise,Leak, easy for start and off, no spark ( Tidak
●
berisik,bocor,mudah di hidup dan matikan, tidak ada percikan api)
26 Air cleaner assy No leak (tidak bocor) ●
27 Counter weight assy Available,tight and no crack (ada,rapat dan tidak retak) ● ●
28 Front outrigger jacks No leak, work properly (tidak bocor, berfungsi dengan baik) ● ●
29 Rear outrigger jacks No leak, work properly (tidak bocor, berfungsi dengan baik) ● ●
30 Drive or rear wheels No crack,recondition,bare (tidak retak,rekondisi,gundul) ●
31 Turn table Work properly (berfungsi dengan baik) ●
32 Hydraulic tank assy No leak, level normal condition >40% (tidak bocor,level normal
● ●
>40%)
33 Hydroulic system (sistem hidrolik) No Corrotion, no leak,work and smothly (tidak berkarat, tidak
bocor,berfungsi dan lancar) ● ●

INSPECTION STATUS
PASSED

HOLD

REJECTED

SPECIAL NOTE FROM CLIENT:

INSPECTION BY APPROVED BY

Name and Signature Name and Signature

Stiker Number

Stiker Number

Stiker Number

BG-06221IDa2.xlsx
 Security Level 2
BG-06221ID
8
Appendix (2)- /89
Form no: Form-I-002A

Inspection Date :
TRUCK/MOBILE CRANE TELESCOPIC BOOM Location of Inspection :
Company/Subcontractor :

DAILY CHECK LIST Validty of inspection :

ID No. :
(PER.08/MEN/2020 PESAWAT ANGKAT DAN PESAWAT ANGKUT)
This form must be completed by the operator and leader user before the equipment to be operated. All equipment conditon must meet to the safety regulation, government regulation and IKPT SHES Plan.
Period: / / to / /
No INSPECTION ITEM STANDARDS REASON FOR NOT COMPLY
Senin Selasa Rabu kamis Jumat Sabtu Minggu
1 Main Engine (mesin utama) No abnormal noise,no Leak, easy for start and off, no
spark (Tidak berisik, bocor,mudah di hidup dan
matikan, tidak ada percikan api)
2 Engine starting Easy for start and stop (mudah untuk dinyalakan dan
matikan)
3 Battery ( Accu ) Tight and lock (rapat dan terkunci)
4 Fuel tank cover Tight and lock (rapat dan terkunci)
5 Radiator No leak (tidak bocor)
6 Horn (klakson) Work properly (berfungsi dengan baik)
7 Exhaust system (sistem No leak ( tidak bocor)
buangan/knalpot)
8 Fuel system ( sistem bahan bakar) No leak (tidak bocor)
9 Rear view mirrors (kaca spion) Work properly (berfungsi dengan baik)
10 Windshied wipers Work properly (berfungsi dengan baik)
11 Turning lights ( lampu sein) Work properly (berfungsi dengan baik)
12 Stop lights (lampu stop) Work properly (berfungsi dengan baik)
13 Rotary Lamp Work properly (berfungsi dengan baik)
14 Reverse lamp and sign (lampu Work properly (berfungsi dengan baik)
mundur dan bel)
15 Break system (sistem pengereman) Work properly (berfungsi dengan baik)
16 Test all function Work properly for all device (semuanya berfungsi dengan
system baik)
(Electrical/hydrolic)
17 Back Mirror Work properly (berfungsi dengan baik)
18 Tire or Crawler No crack, no bare (tidak retak, tidak gundul)
19 Fire Extinguisher Fire extinguisher have to install inside cabine operator (
Apar harus tersedia di dalam ruangan operator )
20 First Aid Box Avilable (ada)
21 Panel Instrument indicator Work properly (berfungsi dengan baik)
22 Safety lutch Work properly (berfungsi dengan baik)
23 Anti two block Work properly (berfungsi dengan baik)
24 *Load indicator ( Alarm sound, Work properly (berfungsi dengan baik)
external
25 *Load moment indicator ( Cut Work properly (berfungsi dengan baik)
off engine)
26 Main hook block ( Hook utama ) No crack,work properly,grease (tidak retak,berfungsi
dengan baik,terlumasi)
27 Main hoist line ( beban penggerak No broke of wire, greased (tidak putus pada
utama ) wiring,terlumasi)
28 Auxilary Hook Available and work properly (ada dan bekerja baik)
29 Auxilary Line Available and work properly (ada dan bekerja baik)
30 Tip or upper boom Available and work properly (ada dan bekerja baik)
31 Mid boom Work properly (berfungsi dengan baik)
32 Base or lower boom Work properly (berfungsi dengan baik)
33 Lift cylinder Work properly (berfungsi dengan baik)
34 Boom pivoting No crack,work properly (tidak retak,berfungsi dengan
35 Main load drum Work properly (berfungsi dengan baik)
36 Auxilary load drum Work properly (berfungsi dengan baik)
37 Wire Sling No rusty, crack, no broken (tidak berkarat, retak, putus)
38 Cabin operator Clean, no oil spill (bersih,tidak ada tumpahan minyak)
39 Boom rest No crack and work properly (tidak retak dan
berfungsi dengan baik)
40 Driver cabin assy Clean, no oil spill (bersih,tidak ada tumpahan minyak)
41 Truck or lower engine No noise,Leak, easy for start and off, no spark ( Tidak
berisik,bocor,mudah di hidup dan matikan, tidak ada
42 Air cleaner assy No leak (tidak bocor)
43 Counter weight assy Tight and no crack (ada,rapat dan tidak retak)
44 Front outrigger jacks No leak, work properly (tidak bocor, berfungsi dengan
45 Rear outrigger jacks No leak, work properly (tidak bocor, berfungsi dengan
46 Drive or rear wheels No crack, no bare (tidak retak, tidak gundul)
47 Turn table Work properly (berfungsi dengan baik)
48 Hydraulic tank assy No leak, level normal condition >40% (tidak bocor,level
normal >40%)
49 Hydroulic system (sistem hidrolik) No Corrotion, no leak, work and smothly (tidak berkarat,
tidak bocor,berfungsi dan lancar)

OPERATOR
SIGNED BY
LEADER

BG-06221IDa2.xlsx
 Security Level 2
BG-06221ID
9
Appendix (2)- /89
Form no: Form-I-002A

Inspection Date :
TRUCK/MOBILE CRANE TELESCOPIC BOOM Location of Inspection :
Company/Subcontractor :

DAILY CHECK LIST Validty of inspection :

ID No. :
(PER.08/MEN/2020 PESAWAT ANGKAT DAN PESAWAT ANGKUT)
This form must be completed by the operator and leader user before the equipment to be operated. All equipment conditon must meet to the safety regulation, government regulation and IKPT SHES Plan.

REMARKS

BG-06221IDa2.xlsx
 Security Level 2
BG-06221ID
Appendix (2)-
10 /89
Form No: Form-I-003

TRUCK MOUNTED CRANE

Inspection Date :
Location of Inspection :
Company/Subcontractor :
INSPECTION STANDARD Validty of inspection :
Type of inspection : Monthly for High Risk/ every 3 Months
(PER.08/MEN/2020 PESAWAT ANGKAT DAN PESAWAT ANGKUT)
This form must be completed by the operator and company user before entering the equipment to site project and to be operated. All equipment conditon must meet to the safety regulation, government regulation and IKPT
SHES Plan.
EQUIPMENT CARRY-IN CERTIFICATE
Type: Police No:
Machine/Engine No: Certificate (STNK) No:
Serial/Plate/Body No.: Certifcate Validity:
Manufacture / Year: Validity Vehicle test by Government (KIR):
Lifting manufacture / Year: Equip. Operation license (SILO/SIA) no.:
Capacity: Equip. Operation license (SILO/SIA) Validity:
Serial Lifting No: Operator Name:
ID No: Operator License (SIO) No. :
Operator license (SIO) Validity:
INSPECTION METHOD INSPECTION RESULT
No INSPECTION ITEM STANDARDS REASON FOR NOT COMPLY
VISUAL FUNCTION IKPT CLIENT
Common

1 Maintenance record For the pass year is available ●

2 Daily check list For the pass 3 months is available ●
3 Wheel Tire (ban) Are inflated and free of excessive wear or damage. Nuts are
tight (tidak kempes dan rusak.baut rapat, roda depan bukan ●
vulkanisir)
4 Fuel tank cover (tutup bahan Tight,manufacturing standard (rapat,standard pabrikan)
bakar) ●
5 Fuel tank (tangki bahan bakar) No leak (tidak bocor)
●
6 battery cover (tutup accu) Cover all surface,isolator matrial (menutupi seluruh
permukaan,terbuat ●
7 Rearviwe mirror (kaca spion) Clearly (jelas) ●
8 Horn (klakson) Properly function (berfungsi dengan baik)
●
9 Engine (mesin) Easy start and stop, no spark (mudah dihidup dan matikan,tidak
ada ● ●
percikan)
10 Brake, Parking brake (rem, rem Properly function (berfungsi dengan baik)
parkir/handrem) ●
11 Headlamp (lampu utama) Properly function (berfungsi dengan baik)
● ●
12 Signal lamp (lampu sein) Properly function (berfungsi dengan baik) `
● ●
13 Rotary Lamp Properly function (berfungsi dengan baik)
● ●
14 Radiator above min. level (diatas ambang batas min)
● ●
15 Gauge indicator cabin (panel Properly function (berfungsi dengan baik)
indikator kabin) ●
16 Reverse Light and sign (lampu Properly function (berfungsi dengan baik)
mundur dan bel) ● ●
17 Wiper Properly function (berfungsi dengan baik) ●
18 Fire extinguisher (APAR) Still seal and not expired (tersegel dan tidak kadaluarsa) ●
19 First Aid Box Available (ada) ●
Special Requirement

1 2 or 4 ore more wheel drive Properly function (berfungsi dengan baik) ● ●

2 Hydroulic system (sistem No leak,work and smothly (tidak bocor,berfungsi dan lancar)
hidrolik) ● ●
3 Oil hydroulic (oli hirolik) Above min.level (diatas ambang batas min) ● ●
4 Hook (gantungan) Work,greased,safety lack work,not crack,bent (berfungsi, greasing,
safty lacknya berfungsi, tidak retak, bengkok) ● ●
5 Load Chart Available (ada) ●
6 Outrigger jacks No leak, work properly (tidak bocor, berfungsi dengan baik) ● ●

INSPECTION STATUS Hydraulic System

PASSED

HOLD
Hydraulic absorber
REJECTED Hook

Mirror
SPECIAL NOTE FROM CLIENT :

Wiper
INSPECTION BY APPROVED BY
Tire Rear lamp
Out rigger Fuel Tank
Name and Signature Name and Signature Signal lamp
Stiker Number

Stiker Number

Stiker Number

BG-06221IDa2.xlsx
 Security Level 2
BG-06221ID
Appendix (2)-

Form No: Form-I-003A

11 /89

Inspection Date :
TRUCK MOUNTED CRANE Location of Inspection :
Company/Subcontractor :
DAILY CHECK LIST Validty of inspection :
ID No:
(PER.08/MEN/2020 PESAWAT ANGKAT DAN PESAWAT ANGKUT)
This form must be completed by the operator and leader user before the equipment to be operated. All equipment conditon must meet to the safety regulation, government regulation and IKPT SHES Plan.
Period: / / to / /
No INSPECTION ITEM STANDARDS REASON FOR NOT COMPLY
Senin Selasa Rabu kamis Jumat Sabtu Minggu

1 Wheel Tire (ban) Are inflated and damage. (tidak kempes dan rusak)
2 Fuel tank cover (tutup bahan Tight,manufacturing standard (rapat,standard pabrikan)
bakar)
3 Fuel tank (tangki bahan bakar) No leak (tidak bocor)

4 Battery cover (tutup accu) Cover all surface,isolator matrial (menutupi seluruh
permukaan,terbuat
5 Battery cable connections Are tight (rapat)
(sambungan kabel accu)
6 Rearviwe mirror (kaca spion) Clearly (jelas)
7 Horn (klakson) Properly function (berfungsi dengan baik)

8 Engine (mesin) Easy start and stop, no spark (mudah dihidup dan matikan,tidak
ada
9 Brake, Parking/ hand brake Properly function (berfungsi dengan baik)
(rem, rem parkir/handrem)
10 Headlamp (lampu utama) Properly function (berfungsi dengan baik)

11 Signal lamp (lampu sein) Properly function (berfungsi dengan baik)

12 Rotary Lamp Properly function (berfungsi dengan baik)

13 Radiator above min. level (diatas ambang batas min)

14 Gauge indicator cabin (panel Properly function (berfungsi dengan baik)

indikator kabin)
15 Reverse Light and sign (lampu Properly function (berfungsi dengan baik)
mundur dan bel)
16 Wiper Properly function (berfungsi dengan baik)
17 Fire extinguisher (APAR) Still seal and not expired (tersegel dan tidak kadaluarsa)
18 First Aid Box Available (ada)
19 Hydroulic system (sistem No leak,work and smothly (tidak bocor,berfungsi dan lancar)
hidrolik)
20 Oil hydroulic (oli hirolik) Above min.level (diatas ambang batas min)
21 Hook (gantungan) Work,greased,safety lack work,not crack,bent (berfungsi,
greasing, safty lacknya berfungsi, tidak retak, bengkok)
22 Outrigger jacks No leak, work properly (tidak bocor, berfungsi dengan baik)

OPERATOR
SIGNED BY
LEADER
REMARKS
Hydraulic System

Hydraulic absorber
Hook

Mirror

Wiper
Tire
Out Rear lamp
Fuel Tank
rigger Signal lamp

BG-06221IDa2.xlsx
 Security Level 2
BG-06221ID
Appendix (2)-
12 /89
Form No. : Form-I-004
Inspection Date :
METAL SLING Location of Inspection :
Company/Subcontractor :

INSPECTION STANDARD Validty of inspection :

Seri No. :
Type of inspection : Monthly for High Risk/ every 3 Months
(PER.08/MEN/2020 PESAWAT ANGKAT DAN PESAWAT ANGKUT)
INSPECTION METHOD INSPECTION RESULT
No INSPECTION ITEM STANDARDS REASON FOR NOT COMPLY
VISUAL FUNCTION IKPT CLIENT
No corrosive,crack, no broken (tidak berkarat,crack, tida ada yang
1 Wire ●
putus)
2 Clamp sling Tight,no corrosive,crack (rapat,tidak karat,retak) ●

3 Load rating Valid and readable (valid and terbaca) ●

4 Welded and joint No crack (tidak retak) ●

5 Lack and flexibility Flexible ●

6 Distortion and twisting No distortion ●

INSPECTION STATUS

PASSED

HOLD

REJECTED

SPECIAL NOTE FROM CLIENT :

INSPECTION BY APPROVED BY

Name and Signature Name and Signature

Stiker Number

Stiker Number

Stiker Number

BG-06221IDa2.xlsx
 Security Level 2
BG-06221ID
Appendix (2)-
13 /89
Form No. : Form-I-004
Inspection Date :
WEBBING SLING Location of Inspection :
Company/Subcontractor :

INSPECTION STANDARD Validty of inspection :

Seri No. :
Type of inspection : Monthly for High Risk/ every 3 Months
(PER.08/MEN/2020 PESAWAT ANGKAT DAN PESAWAT ANGKUT)
INSPECTION METHOD INSPECTION RESULT
No INSPECTION ITEM STANDARDS REASON FOR NOT COMPLY
VISUAL FUNCTION IKPT CLIENT
Common

1 Sling woven (anyaman sling) No broken,melted,abrasive (tidak rusak,leleh,abrasive) ●

2 Manufacturing certificate Valid and readable (valid and terbaca) ●
3 Eye hole No deformed ●
4 Load rating Valid from authority juridiction (valid,dari pihak yang berwenang) ●

INSPECTION STATUS

PASSED

HOLD

REJECTED

SPECIAL NOTE FROM CLIENT :

INSPECTION BY APPROVED BY

Name and Signature Name and Signature

Stiker Number

Stiker Number

Stiker Number

BG-06221IDa2.xlsx
 Security Level 2
BG-06221ID
Appendix (2)-
14 /89
Form No. : Form-I-006
Inspection Date :
SHACKLE Location of Inspection :
Company/Subcontractor :

INSPECTION STANDARD Validty of inspection :

Seri No. :
Type of inspection : Monthly for High Risk/ every 3 Months
(PER.05/MEN/1985 PESAWAT ANGKAT DAN ANGKUT)
INSPECTION METHOD INSPECTION RESULT
No INSPECTION ITEM STANDARDS REASON FOR NOT COMPLY
VISUAL FUNCTION IKPT CLIENT
Valid from juridiction authority (valid dari badan yang
1 Certificate ●
berwenang)
2 Load rating Clear and readable (jelas dan terbaca) ●

3 Pin hole Lock tight (mengunci dengan rapat) ●

4 Scakle body Not crack and bent (tidak retak dan bengkok) ●

INSPECTION STATUS

PASSED

REJECT

HOLD

SPECIAL NOTE FROM CLIENT :

INSPECTED BY APPROVED BY

Name and Signature Name and Signature

Stiker Number

Stiker Number

Stiker Number

BG-06221IDa2.xlsx
 Security Level 2
BG-06221ID
Appendix (2)-
15 /89
Forn No. : Form-I-007
Inspection Date :
BLOCK & TACKLE Location of Inspection :
Company/Subcontractor :

INSPECTION STANDARD Validty of inspection :

Seri No. :
Type of inspection : Monthly for High Risk/ every 3 Months
(PER.08/MEN/2020 PESAWAT ANGKAT DAN PESAWAT ANGKUT)
INSPECTION METHOD INSPECTION RESULT
No INSPECTION ITEM STANDARDS REASON FOR NOT COMPLY
VISUAL FUNCTION IKPT CLIENT
1 Hook Not crack (tidak retak) ●
2 Safety lutck Work (berfungsi) ●
3 Pea hook Not crack (tidak retak) ●
4 Becket On position,not crack (pada tempatnya,tidak retak) ● ●
5 Block cheek Not crack and covering part (tidak retak danmenutupi part) ●
6 Thimble Work (berfungsi) ●
7 Pin lock Tight (rapat) ●
8 Equipment tag Availlable and clear (tersedia dan jelas) ●
9 sheave Work (berfungsi) ●
10 Load rating Availlable (tersedia) ●
11 Certificate for chain As manufacturing standard (sesuai dengan standar pabrikan) ●
12 Chain connection Not crack (tidak retak) ●
13 Chain Not corrosive (tidak berkarat) ●
14 Lever *if any sling and rope Work (berfungsi) ●
15 Sling rope Max.wire broken 2 ●
16 Rope Not abrasive (tidak abrasif) ●
17 Strap Not molted,scratch and abrasif (tidak melele,sobek danabrasif) ●

INSPECTION STATUS

PASSED

REJECT

HOLD

SPECIAL NOTE FROM CLIENT :

INSPECTED BY APPROVED BY

Name and Signature Name and Signature

Stiker Number

Stiker Number

Stiker Number

BG-06221IDa2.xlsx
 Security Level 2
BG-06221ID
Appendix (2)-16/89

Form No: Form-I-008

CHAIN BLOCK
Inspection Date :
Location of Inspection :
Company/Subcontractor :

INSPECTION STANDARD Validty of inspection :

Seri No. :
Type of inspection : Monthly for High Risk/ every 3 Months
(PER.05/MEN/1985 PESAWAT ANGKAT DAN ANGKUT)
INSPECTION METHOD INSPECTION RESULT
No INSPECTION ITEM STANDARDS REASON FOR NOT COMPLY
VISUAL FUNCTION IKPT CLIENT
1 Top Hook Sturdy and Not Crack (Kokoh dan Tidak Retak) ●
2 Gear Box Sturdy (Kokoh) ●
3 Handweel Under Cover Smooth and Wheel Not Crack (Gesekan Halus dan Roda Gigi danTidak ●
Retak)
4 Hand Cain Sturdy and Not Crack (Kokoh dan Tidak Retak) ●
5 Load Chain Sturdy and Not Crack (Kokoh dan Tidak Retak) ●
6 Load Block Sturdy and Not Crack (Kokoh dan Tidak Retak) ●
7 Hook Latch Sturdy and Good to Lock (Kokoh dan mengunci Kuat) ●
8 Load Hook Sturdy and Not Crack (Kokoh dan Tidak Retak) ●

INSPECTION STATUS
PASSED

REJECT
Geat Box
HOLD

SPECIAL NOTE FROM CLIENT:

INSPECTED BY APPROVED BY

Name and Signature Name and Signature

Stiker Number

Stiker Number

Stiker Number

BG-06221IDa2.xlsx
 Security Level 2
BG-06221ID
Appendix (2)-16/89
Form No: Form-I-009
Inspection Date :
CHAIN SLING Location of Inspection :
Company/Subcontractor :
Validty of inspection :
INSPECTION STANDARD Seri No. :
Type of inspection : Monthly for High Risk / every 3 Months
(PP/No.50/2012)
INSPECTION METHOD INSPECTION RESULT
No INSPECTION ITEM STANDARDS REASON FOR NOT COMPLY
VISUAL FUNCTION IKPT Client
1 Link by link of chain No crack,bent,stretched,heat damage (tidak retak,bengkok,rusak ●
karena panas)
2 Capacity tag Available,readable (tersedia,terbaca) ●
3 Master link or coupling No deformed ●
4 Certicate Valid from authority juridiction (valid,dari pihak yang berwenang) ●

5 Hook Safety lack work,no bent (pengunci berfungsi,tidak bengkok) ●

6 Chain Not corrosive (tidak berkarat) ●

INSPECTION STATUS

PASSED

HOLD

REJECTED

SPECIAL NOTE FROM CLIENT :

INSPECTION BY APPROVED BY

Name and Signature Name and Signature

Stiker Number

Stiker Number

Stiker Number

BG-06221IDa2.xlsx
 Security Level 2
BG-06221ID
Appendix (2)-
18 /89
Form no.: Form-I-010
Inspection Date :
FORKLIFT Location of Inspection :
Company/Subcontractor :

INSPECTION STANDARD Validty of inspection :

Seri No. :
(PER.08/MEN/2020 PESAWAT ANGKAT DAN PESAWAT ANGKUT) Type of inspection : Monthly for High Risk/ every 3 Months
This form must be completed by the operator and company user before entering the equipment to site project and to be operated. All equipment conditon must meet to the safety regulation, government regulation and IKPT
SHES Plan.
EQUIPMENT CARRY-IN CERTIFICATE
Type: Police No:
Machine/Engine No: Certificate (STNK) No:
Serial/Plate/Body No.: Certifcate Validity:
Manufacture / Year: Validity Vehicle test by Government (KIR):
Lifting manufacture / Year: Equip. Operation license (SILO/SIA) no.:
Capacity: Equip. Operation license (SILO/SIA) Validity:
Serial Lifting No: Operator Name:
ID No: Operator License (SIO) No. :
Operator license (SIO) Validity:
INSPECTION METHOD INSPECTION RESULT
No INSPECTION ITEM STANDARDS REASON FOR NOT COMPLY
VISUAL FUNCTION IKPT CLIENT
Common
1 Maintenance record For the pass year is available ●
2 Daily check list For the pass 3 months is available ●
Wheel Tires (Ban) not inflatet, as manufacturing standard,for(Tidak bocor, ●
3
kondisi masih
4 Engine oil (oli mesin) is full and free of leaks (penuh,tidak bocor) ●
5 Hydraulic oil (oli hidrolic) is full and free of leaks (penuh,tidak bocor) ●
6 Radiator is full and free of leaks (penuh,tidak bocor) ●
Fuel Cap (tutup bahan bakar) as manufacturing standard, tight (sesuai dengan standard ●
7
pabrikan,
Battery connections (sambungan kabel are tight (rapat) ●
8
accu)
battery cover (tutup accu) secure and isolator material( rapat dan bahan isolator) ●
9
Seat safety belt ( sabuk pengaman) is accessible and not damaged, oily, or dirty (mudah ●
10 dijangkau,tidak rusak/berminyak/kotor)
Engine (mesin) Not leaks and no sparks from the exhaust (tidak bocor, tidak ●
11
ada percikan api dari knalpot)
12 Horn (klakson) Good functiong (berfungsi) ●
Turn signal (bunyi sein) Operates smoothly (berfungsi dengan baik) ● ●
13
Reverves signal (bunyi mundur) Operates smoothly (berfungsi dengan baik) ● ●
14
Lights (head, tail, and warning) (lampu Work and are aimed correctly (berfungsi dengan baik) ● ●
15
: atas, belakang, peringatan)
16 Gauges and instruments Good functiong (berfungsi) ● ●

Steering (kemudi) Smooth and responsive free of excessive play (berfungsi ●

17
dengan baik dan responsif ketika diputar)
18 Brakes (rem) Good Function (berfungsi baik) ●

Fire extinguisher (APAR) is available,not expired,easy for taking (tersedia,tidak ●

19
kadaluarsa, mudah untuk diambil)
First Aid Box Available (ada ●
20
Special Requirement
Not bent, worn, or cracked. Upper limit stops are OK (tidak ● ●
1 Forks and mast (garpu dan tiangnya) bengkok,licin,retak. Maksimum angkat berfungsi)

Load back rest extension (sandaran In place and not bent, cracked, or loose (terletak ● ●
2
beban) ditempatnya, tidak bengkok/retak/loose)
In place and not bent, cracked, or loose (terletak ●
3 Overhead guard (pelindung atas/atap)
ditempatnya, tidak bengkok/retak/loose)
4 Forklift body(badan forklift) free from grease, oil (bebas dari grease, oli) ●
In place and readable (pada tempatnya dan terbaca) ●
5 Load rating plate (papan rating beban)

Warning decals (peringatan Operators' manual are present and readable (terdapat ●
6 pemakaian) manual operasi dan terbaca)
Operates smoothly without excessive drift (berfungsi dengan ●
7 Lift and lower (atas dan bawah)
baik tanpa hambatan)
Operates smoothly without, excessive drift or "chatter" ●
8 Tilt (kemiringan)
(berfungsi dengan baik tanpa decitan)
9 Control levers (presneling) Good Function (berfungsi dengan baik) ●
Parking brake (rem parkir/rem tangan) Good Function (berfungsi dengan baik) ●
10
11 Backup alarm (if equipped) Good Function (berfungsi dengan baik) ●
Fire extinguisher (APAR) is available,not expired,easy for taking (tersedia,tidak ●
12
kadaluarsa, mudah untuk diambil)
Hose line not crack,leak(slang tidak retak,bocor) ● ●
Regulator tight,work,measured press. Work(regulator ● ●
13 Fuel Gas System (bahan bakar gas) rapat,berfungsi,pengukuran tekanan berfungsi)
Lpg cage is tight,safety lutch work properly (tempat lpg rapat, ● ●
pengunci berfungsi)
Tight, min. as IKPT standard (rapat, min. sesuai dengan ●
14 Flame arrestor (saringan knalpot)
standar IKPT)

BG-06221IDa2.xlsx
 Security Level 2
BG-06221ID
Appendix (2)-
19 /89
Form no.: Form-I-010
Inspection Date :
FORKLIFT Location of Inspection :
Company/Subcontractor :

INSPECTION STANDARD Validty of inspection :

Seri No. :
Type of inspection : Monthly for High Risk/ every 3 Months
(PER.08/MEN/2020 PESAWAT ANGKAT DAN PESAWAT ANGKUT)
This form must be completed by the operator and company user before entering the equipment to site project and to be operated. All equipment conditon must meet to the safety regulation, government regulation and IKPT
SHES Plan.
INSPECTION STATUS
Overhead Guard Cross head
Rear View
PASSED
Mirror
HOLD Lifting Chain
Signal
REJECTED Mask
Lamp

Carriage
SPECIAL NOTE FROM CLIENT: Seat
Belt

Fork
INSPECTION BY APPROVED BY Fuel

Tire Body Steering

Name and Signature Name and Signature
Head Lamp
Stiker Number

Stiker Number

Stiker Number

BG-06221IDa2.xlsx
 Security Level 2
BG-06221ID

Appendix (2)-
Form no.: Form-I-010A
Inspection Date :
FORKLIFT Location of Inspection :
Company/Subcontractor :
DAILY CHECK LIST Validty of inspection :
ID No:
(PER.08/MEN/2020 PESAWAT ANGKAT DAN PESAWAT ANGKUT)
This form must be completed by the operator and leader user before the equipment to be operated. All equipment conditon must meet to the safety regulation, government regulation and IKPT SHES Plan.
Period: / / to / /
No INSPECTION ITEM STANDARDS Senin Selasa Rabu kamis Jumat Sabtu Minggu REASON FOR NOT COMPLY
Wheel Tires (Ban) not inflatet, as manufacturing standard,for(Tidak bocor,
1
kondisi masih
2 Engine oil (oli mesin) is full and free of leaks (penuh,tidak bocor)
3 Hydraulic oil (oli hidrolic) is full and free of leaks (penuh,tidak bocor)
4 Radiator is full and free of leaks (penuh,tidak bocor)
Fuel Cap (tutup bahan bakar) as manufacturing standard, tight (sesuai dengan standard
5
pabrikan,
Battery cable connections (sambungan Are tight (rapat)
6
kabel accu)
battery cover (tutup accu) secure and isolator material( rapat dan bahan isolator)
7
Seat safety belt (sabuk pengaman) is accessible and not damaged, oily, or dirty (mudah
8 dijangkau,tidak rusak/berminyak/kotor)
Engine (mesin) Not leaks and no sparks from the exhaust (tidak bocor, tidak
9 ada percikan api dari knalpot)
10 Horn (klakson) Good functiong (berfungsi)
Turn signal (bunyi sein) Operates smoothly (berfungsi dengan baik)
11
Reverves signal (bunyi mundur) Operates smoothly (berfungsi dengan baik)
12
Lights (head, tail, and warning) (lampu Work and are aimed correctly (berfungsi dengan baik)
13
:
atas, belakang, peringatan)
Steering (kemudi) Smooth and responsive free of excessive play (berfungsi
14
dengan baik dan responsif ketika diputar)
15 Brakes (rem) Good Function (berfungsi baik)

Lift and lower (atas dan bawah) Operates smoothly without excessive drift (berfungsi
16
dengan
baik tanpa hambatan)
17 Control levers (presneling) Good Function (berfungsi dengan baik)
18 Parking brake (rem parkir/rem tangan) Good Function (berfungsi dengan baik)
Hose line not crack,leak (slang tidak retak,bocor)
Regulator tight,work,measured press. Work(regulator
19 Fuel Gas System (bahan bakar gas) rapat,berfungsi,pengukuran tekanan berfungsi)
Lpg cage is tight,safety lutch work properly (tempat lpg
rapat, pengunci berfungsi)
Fire extinguisher (APAR) is available,not expired,easy for taking (tersedia,tidak
20 kadaluarsa, mudah untuk diambil)
21 First Aid Box Available (ada)

OPERATOR
SIGNED BY
LEADER

REMARK Overhead Guard Cross head

Rear View

Lifting
Signal Mask
Lamp
Carriage
Seat Belt

Fork
Fuel

Tire Body Steering

Head Lamp

BG-06221IDa2.xlsx
 Security Level 2
BG-06221ID

Appendix (2)-
Form no: Form-I-021
Inspection Date :
Location of Inspection :
Company/Subcontractor :
MANLIFT INSPECTION STANDARD
Validty of inspection :
Type of inspection : Monthly for High Risk/ every 3 Months
This form must be completed by the operator and company user before entering the equipment to site project and to be operated. All equipment conditon must meet to the safety regulation,
government regulation and IKPT SHES Plan.
EQUIPMENT CARRY-IN CERTIFICATE
Type: Police No:
Machine/Engine No: Certificate (STNK) No:
Serial/Plate/Body No.: Certifcate Validity:
Manufacture / Year: Validity Vehicle test by Government (KIR):
Lifting manufacture / Year: Equip. Operation license (SILO/SIA) no.:
Capacity: Equip. Operation license (SILO/SIA) Validity:
Serial Lifting No: Opertor Name:
ID No: ML - …………… Operator License (SIO) No. :
Operator license (SIO) Validity:
CODE Series INSPECTION INSPECTION
No. INSPECTION ITEM STANDARDS VISUAL FUNCTION IKPT CLIENT REASON FOR NOT COMPLY
Basic inspection (from ground):
1 Manufacturer’s manual Available (ada) ●
2 Maintenance record For the pass year is available ●
3 Daily check list For the pass 3 months is available ●
4 Platform/railing Bent, worn, damaged, locking ●
5 Tires Not inflated, as manufacturing standard
(Tidak bocor, kondisi masih aman ●
sesuai dengan pabrikan)
6 Fire extinguisher Fully charged, sealed and inspected
(terisi penuh, disegel dan sudah ●
diinspeksi)
7 Horn Work (Berfungsi dengan baik) ● ●
8 Restraining device Good and secure (baik dan aman) ●
9 Hydraulic fluid work,no leak,no noise (berfungsi,tidak
bocor, tidak bersisik) ● ●
10 Hoses No corrosive,leak,crack (tidak
karat,bocor, retak) ● ●
11 Warning light and sound Good and function (bagus dan
berfungsi) ● ●
Internal Engine:
11 Fuel tank Not leak (tidak bocor) ●
12 Fuel tank cap No leak and cap is tight (tidak bocor
dan tutup rapat) ●
13 Engine oil Max. oil, Not leak (Oli penuh, tidak
bocor) ●
14 Radiator No leak and cap is tight (tidak bocor
dan tutup rapat) ●
15 Hydraulic fluid ( platform down) work,no leak,no noise (berfungsi,tidak
bocor, tidak bersisik) ● ●
16 Hoses and belts (good repair) No corrosive,leak,crack (tidak
karat,bocor, retak) ● ●
Battery powered equipment:
17 Battery No leak and cap is tight (tidak bocor
dan tutup rapat) ●
18 Cables and connections Tight dan no defective (kencang dan
tidak cacat) ●
19 Cell levels Above plates (diatas plat) ●
20 Plugging control Smooth operation ●
Basic inspection (on manlift):
21 Brake pin & linkage Work and no noise (berfungsi dan tidak ●
22 Brake Firm and stops smoothly (kuat dan
berhenti dengan lancar) ● ●
23 Steering Smooth operation (operasi lancar) ● ●
24 Hydrolic (under manlift) Work,no leak,no noise (berfungsi,tidak
bocor, tidak bersisik) ●
25 Hydraulic controls Smooth operation (operasi lancar) ● ●
26 hydraulic functions (up/down) Smooth operation (operasi lancar) ● ●
27 Directional controls Smooth operation (operasi lancar) ● ●

BG-06221IDa2.xlsx
 Security Level 2
BG-06221ID

Appendix (2)-
Form no: Form-I-021
Inspection Date :
Location of Inspection :
Company/Subcontractor :
MANLIFT INSPECTION STANDARD
Validty of inspection :
Type of inspection : Monthly for High Risk/ every 3 Months
This form must be completed by the operator and company user before entering the equipment to site project and to be operated. All equipment conditon must meet to the safety regulation,
government regulation and IKPT SHES Plan.
INSPECTION STATUS
PASSED

HOLD

REJECTED

SPECIAL NOTE FROM CLIENT :

INSPECTION BY APPROVED BY

Name and Signature Name and Signature

Stiker Number

Stiker Number

Stiker Number

BG-06221IDa2.xlsx
 Security Level 2
BG-06221ID

Appendix (2)-
Form no: Form-I-021A
Inspection Date :
Location of Inspection :
Company/Subcontractor :
MANLIFT INSPECTION DILY CHECK LIST Validty of inspection :
ID NO: ML- …...
This form must be completed by the operator and leader user before the equipment to be operated. All equipment conditon must meet to the safety regulation, government regulation and IKPT SHES Plan.
Period: / / to / /
No. INSPECTION ITEM STANDARDS Senin Selasa Rabu kamis Jumat Sabtu Minggu REASON FOR NOT COMPLY

1 Tires Not inflated, as manufacturing standard

(Tidak bocor, kondisi masih aman
sesuai dengan pabrikan)
2 Horn Work (Berfungsi dengan baik)
3 Restraining device Good and secure (baik dan aman)
4 Hydraulic fluid work,no leak,no noise (berfungsi,tidak
bocor, tidak bersisik)
5 hydraulic functions (up/down) Smooth operation (operasi lancar)
6 Directional controls Smooth operation (operasi lancar)
7 Warning light and sound Good and function (bagus dan
berfungsi)
8 Fuel tank Not leak (tidak bocor)
9 Fuel tank cap No leak and cap is tight (tidak
bocor dan tutup rapat)
10 Engine oil Max. oil, Not leak (Oli penuh, tidak
bocor)
11 Radiator No leak and cap is tight (tidak
bocor dan tutup rapat)
12 Battery No leak and cap is tight (tidak
bocor dan tutup rapat)

13 Cables and connections Tight dan no defective (kencang dan

tidak cacat)
14 Plugging control Smooth operation
15 Brake pin & linkage Work and no noise (berfungsi dan tidak
bersisik)
16 Brake Firm and stops smoothly (kuat dan
berhenti dengan lancar)
17 Steering Smooth operation (operasi lancar)

OPERATOR
SIGNED BY
LEADER
REMARKS

BG-06221IDa2.xlsx
 Security Level 2
BG-06221ID

Appendix (2)-
Form No : Form-I-022
Inspection Date :
GONDOLA / CARGO LIFT Location of Inspection :
Company/Subcontractor :

INSPECTION STANDARD Validty of inspection :

Seri No. :
Type of inspection : Monthly for High Risk/ every 3 Months
(PP/50/2012 & OSHA 1910.243)
INSPECTION METHOD INSPECTION RESULT
No INSPECTION ITEM STANDARDS REASON FOR NOT COMPLY
VISUAL FUNCTION IKPT CLIENT
1 Maintenance record For the pass year is available ●
2 Daily check list For the pass 3 months is available ●
3 Overhang Support Arms Calculation avaiable, no corrotion, and defect ●

4 Wire Ropes/Shackles No rusty, no defect and no broken ●

5 Reel Winding/Sheaves No rusty, no defect and no noise ● ●

6 Electro/Mechanic Brakes No defect and good function ● ●

7 Hand Control Device No defect and good function ● ●

8 Stopper/Latches No defect and good function ● ●

9 Cage/Handrail No defect and no rusty ●

10 Bolts/Nuts/Bearing No defect, no rusty and no noise ● ●

11 Control Panel No defect and good function ● ●

12 Motor No defect, no rusty and no noise ● ●

13 Cab tire Cable/Earth No defect, no rusty and no noise ●

Over-Wind Warning Available and good function ●

14
Devices
15 Emergency Stopper all cable connection using junction box ●

16 Lift: Guide Rails/Support Available and no rusty ●

17 Shuttering Doors Available ●

Safe Guards for moving Available ●

18
parts
Limitation of Weigth and Available ●
19
number of person sign
20 Warning sign Available ●

INSPECTION STATUS
PASSED

REJECT

HOLD

SPECIAL NOTE FROM CLIENT :

INSPECTED BY APPROVED BY

Name and Signature Name and Signature

Stiker Number

Stiker Number

Stiker Number

BG-06221IDa2.xlsx
 Security Level 2
BG-06221ID

Appendix (2)-
Form no. : FormI-I-023
Inspection Date :
SCAFFOLDING Location of Inspection :
Company/Subcontractor :

INSPECTION STANDARD
Validty of inspection :
Seri No. :
Type of inspection : Daily / weekly inspection
(OSHA 1926.451)
INSPECTION METHOD INSPECTION RESULT
No INSPECTION ITEM STANDARDS REASON FOR NOT COMPLY
VISUAL FUNCTION IKPT CLIENT
1 Standard of Scaffolding The British Standards (BS)/ Japan standard (JIS) for steel tube
and Coupling and European Standards (EN) for Modular ●
Scaffolds
2 Scaffoldig Material No Combine standard and/or manufacture (tidak dikombinasikan ●
berbeda standard dan/ atau merek)
3 No defect material No bent, Dent and rusty and swivel is good function (tidak ●
bengkok, penyok dan karat dan swivel berfungsi baik)
4 Base Lift
5 Sole Plates the sole Plates from suitable material (Wood, steel etc) and in a ●
serviceable condition (Balok penahan dari bahan yang sesuai
(balok kayu. Besi dll) dan dalam kondisi yang layak
6 Base Plates Available on all legs (ada pada semua kaki) ●
7 Standard/Post Bearing firmly, no bent and plumb (tumpuannya kuat, tidak ●
bengkok dan tegak)
8 Runner/Ledger Level and spaceing between ledger as per design or standard ●
(rata dan jaraknya sesuuai dengan rencana atau standar)

9 Transom/ Bearer Level and spaceing between transom as per design or standard ●
(rata dan jaraknya sesuuai dengan rencana atau standar)

10 Transversal Brace Tightened and no bent (kencang dan tidak bengkok) ●

11 Swivel/ adjustable coupler The joints in standards correctly positioned, correctly secured ●
12 Fix Coupler The joints in standards correctly positioned, correctly secured ●

Midle Lift
1 Standard/Post No bent, the lift heights correct and plumb (tida bengkok, jarak ●
tinggi benar dan tegak)
2 Runner/Ledger Level and spaceing between ledger as per design or standard ●
(rata dan jaraknya sesuai dengan rencana atau standar)

3 Transom/ Bearer Level and spaceing between transom as per design or standard ●
(rata dan jaraknya sesuai dengan rencana atau standar)

4 Transversal Brace Tightened and no bent (kencang dan tidak bengkok) ●

5 Longitudinal Brace Tightened and no bent (kencang dan tidak bengkok) ●
6 Swivel/ adjustable coupler The joints in standards correctly positioned, correctly secured ●
7 Fix Coupler The joints in standards correctly positioned, correctly secured ●

Top Lift
1 Runner/Ledger Level and spaceing between ledger as per design or standard
(rata dan jaraknya sesuai dengan rencana atau standar) ●

2 Transom/ Bearer Level and spaceing between transom as per design or standard
(rata dan jaraknya sesuai dengan rencana atau standar) ●

3 Scaffolding plank (walk way The minimum width of the plank is 25 cm and the minimum
minimum width 50 cm, platform width is 50 cm, tied every 2 planks, there are no holes
working minimum width 60 between the planks. maximum span of 2.4 m.a dn fastened to
cm and working with transom (Lebar minimum papan adalah 25 cm dan lebar platform ●
material minimum width80 minimum adalah 50 cm, diikat setiap 2 papan, tidak ada lubang
cm) di antara papan. rentang maksimum 2,4 m dan diikat ke transom)

4 Toe Board Minimum height 15 cm (tinggi minimum 15 cm) ●

5 Top rail Height no less than 95 cm (ketinggian minimum 95 cm) ●
6 Mid rail Maximum gap between the top of the toe board and any
guardrail 47 cm (jarak maksimum antara bagian atas toe board ●
dan
guardrail apapun 47 cm)
7 False upright Easy to reach, safe and does not interfere with people's traffic
(Mudah dijangkau, aman dan tidak mengganggu lalu lintas ●
orang)
8 Self Closing drop bar Not too heavy but strong to hold people back (Tidak terlalu
berat tetapi kuat untuk menahan orang) ●
9 Ladder Strongth, no dent, 4 : 1 ratio, projecting at least 1.05 m or with
suitable handhold (kuat, tanpa penyok, rasio 4: 1, proyeksinya
setidaknya 1,05 m atau dengan pegangan yang sesuai) ●

Structure
1 Stable and Rigid does not sway when shaken (tidak bergoyang saat terguncang), ● ●
the scaffold effectively guyed or
secured to a building or structure if the scaffold height greater
than three times its minimum base width (perancang ditarik sling
atau di tautkan ke bangunan atau struktur jika tinggi lebih dari
3 kali lebar) and plumb (tegak lurus)
2 Minimum clearance Added goal posts and safety net for safeguard under power lines ●
from overhead power with clearance as per standard (menambahkan goal posts dan
lines jaring pengaman untuk perlindungan dibawah kawat listrik)

3 Maximum clearance from distance Maximum 30 cm ( Jarak minimum 30 cm) ●

permanent wall or structure

BG-06221IDa2.xlsx
 Security Level 2
BG-06221ID

Appendix (2)-
Form no. : FormI-I-023
Inspection Date :
SCAFFOLDING Location of Inspection :
Company/Subcontractor :
Validty of inspection :
INSPECTION STANDARD Seri No. :
Type of inspection : Daily / weekly inspection
(OSHA 1926.451)
4 Warning devices/signs Install safety sign (pasang tanda safety) ●
provided if erected
over walkways or
roadways
5 Exit and entry the location is not disturb construction and traffic activities ●

6 Scaffolding is safe from the location is not disturb equipment traffic activities and put ●
heavy safety sign and tools
equipment traffic

INSPECTION STATUS

PASSE

REJEC

HOL

SPECIAL NOTE FROM CLIENT :

INSPECTED APP ROVED BY

BY

Name and Signature Name and Signature

Stiker Number

Stiker Number

Stiker Number

BG-06221IDa2.xlsx
 Security Level 2
BG-06221ID
Appendix (2)-
Form no. : Form-I-024
Inspection Date :
LADDER Location of Inspection :
Company/Subcontractor :

INSPECTION STANDARD Validty of inspection :

Seri No. :
Type of inspection : Monthly for High Risk/ every 3 Months
(OSHA 29 CFR 1926)
INSPECTION METHOD INSPECTION RESULT
No INSPECTION ITEM STANDARDS REASON FOR NOT COMPLY
VISUAL FUNCTION IKPT Client
1 Stairs/rungs ( anak tangga) Not crack, bent (tidak retak, bengkok) ●
2 anti slip safety available (tersedia) ● ●
3 Body ladder/side rail Free from oil, grease, not crack (tidak terdapat oli, grease, tidak ●
bengkok)
4 Pully rope (tali) ( extention not broken, frayed (tidak rusak, compang camping) ● ●
ladder)
5 Spreader work (berfungsi) ● ●
6 Ladder material Electrical (Fiber) Common (Alumunium) ●
7 Safety Shoe Tight, not crack ( Rapat, tidak retak) ● ●
8 Safe working Load tag availlable,clear (tersedia,jelas) ●

INSPECTION STATUS

PASSED

REJECT

HOLD

SPECIAL NOTE FROM CLIENT :

INSPECTED BY APPROVED BY

Name and Signature Name and Signature

Stiker Number

Stiker Number

Stiker Number

BG-06221IDa2.xlsx
 Security Level 2
BG-06221ID
Appendix (2)-
Form No. : Form-I-030
Inspection Date :
MOLEN CONCRETE Location of Inspection :
Company/Subcontractor :
Validty of inspection :
INSPECTION STANDARD Seri No. :
Type of inspection : Monthly for High Risk/ every 3 Months
INSPECTION METHOD INSPECTION RESULT
No INSPECTION ITEM STANDARDS REASON FOR NOT COMPLY
VISUAL FUNCTION IKPT CLIENT
Tidak Berlubang, Gear tabung tidak rusak dan
1 Concrete Tube ●
berfungsi dengan baik
Berfungsi dengan baik dan mudah dihidup
2 Motor penggerak ● ●
matikan,kelengkapan tersedia
3 Roda Bersfungsi dengan baik untuk perpindahan ●
4 Frame Tidak bengkok dan keropos ●
Steering Wheel/ `
5 Berfungsi dengan baik ● ●
Kemudi pembalik

INSPECTION STATUS
PASSED
steering Wheel Concrete Tank
HOLD
Motor
REJECTED

SPECIAL NOTE FROM CLIENT :

INSPECTION BY APPROVED BY

Wheel
Frame
Name and Signature Name and Signature
Stiker Number

Stiker Number

Stiker Number

BG-06221IDa2.xlsx
 Security Level 2
BG-06221ID
Appendix (2)-
Form No. Form-I-031
Inspection Date :
MIXER TRUCK Location of Inspection :
Company/Subcontractor :
INSPECTION STANDARD Validty of inspection :
Type of inspection : Monthly for High Risk/ every 3 Months
(PER.05/MEN/1985 PESAWAT ANGKAT DAN ANGKUT)
This form must be completed by the operator and company user before entering the equipment to site project and to be operated. All equipment conditon must meet to the safety regulation, government regulation
and IKPT SHES Plan.
EQUIPMENT CARRY-IN CERTIFICATE
Type: Police No:
Machine/Engine No: Certificate (STNK) No:
Serial/Plate/Body No.: Certifcate Validity:
Manufacture / Year: Validity Vehicle test by Government (KIR):
Lifting manufacture / Yeara: Equip. Operation license (SILO/SIA) no.:
Capacity: Equip. Operation license (SILO/SIA) Validity:
Serial Lifting No: Opertor Name:
ID No: MCT - …………. Operator License (SIO) No. :
CODE
Series Operator license (SIO) Validity:
INSPECTION INSPECTION
No INSPECTION ITEM STANDARDS REASON FOR NOT COMPLY
VISUAL FUNCTION IKPT Client
Common
1 Maintenance record For the pass year is available ●
2 Daily check list For the pass 3 months is available ●
3 Wheel Tire (ban) Not inflatet, as manufacturing standard, forward tire not
vulkanisir(Tidak bocor, kondisi masih aman sesuai dengan ●
manufacture, roda depan bukan vulkanisir)
4 Fuel tank cover (tutup bahan as manufacturing standard, tight (sesuai dengan standard
bakar) pabrikan, ●
rapat)
5 Fuel tank no leak (tidak bocor) ●
6 Battery cover (tutup Accu) cover all surface,isolator material ex.rubber (menutupi seluruh
permukaan,matrial isolator ex.karet) ●
7 Rearview mirror (kaca spion) clearly (Jelas) ●
8 Horn (klakson) function (berfungsi) ●
9 Engine (mesin) start smootly and no noise (mudah dihidupkan dan tidak berisik) ●
10 Brake (rem) work smootly (berfungsi dengan baik) ●
11 Headlamp (lampu) as manufacturing standard (sesuai dengan standar pabrikasi) ● ●
12 Signal, brake, rear lamp (lampu Function (berfungsi)
sein, rem dan belakang) ● ●
13 Radiator above min.level, No leak( diatas level min.,tidak bocor) ●
14 Gauge indicator cabin (panel Function (berfungsi)
inidikasi) ●
15 Wiper Function (berfungsi)
●
16 Rotary Lamp Function (berfungsi)
● ●
17 Reverse Lamp and signal Function (berfungsi)
● ●
18 Fire exthinguser (APAR) Still segel and not expired (bersegel dan tidak kadaluarsa) ●
19 Safety cone/triangle sign (safety Available (tersedia)
cone/segitiga) ●
20 First Aid Box Available (tersedia) ●
Special Requirement (Mixer)
1 2 or 4 or 6 Wheel Drive Good Function (berfungsi dengan baik) ● ●
2 All Chutes Secure Latches & Safety hook is good (pengait dan pengaman
dalam konsisi baik) ● ●
3 Hose/pipe line (slang/pipa) No corrosive,leak,crack (tidak karat,bocor,retak)
● ●
4 Hydroulic system (sistem No leaks at all, no noise (tidak bocor, tidak berisik)
hidrolic) ●
5 Oil hydroulic (oli hidrolic) Above min.level, No leak( diatas level min.,tidak bocor) ●
6 Water System No leak at hose and tank Tidak kebocoran di hose dan tank) ● ●
7 No damage and good function (tidak ada rusak dan berfungsi
Hopper ● ●
baik)
8 No tearing and working normally (tidak robek dan berfungsi
Control Cable ● ●
dengan normal)
9 Water tank Glass Clearly (Jelas) ●
10 Roller and Drum No damage and good function (tidak ada rusak dan berfungsi
baik) ● ●

INSPECTION STATUS
PASSED

HOLD

REJECTED

SPECIAL NOTE FROM CLIENT :

BG-06221IDa2.xlsx
 Security Level 2
BG-06221ID
Appendix (2)-
Form No. Form-I-031
Inspection Date :
MIXER TRUCK Location of Inspection :

INSPECTION STANDARD Company/Subcontractor :

Validty of inspection :
(PER.05/MEN/1985 PESAWAT ANGKAT DAN ANGKUT) Type of inspection : Monthly for High Risk/ every 3 Months
This form must be completed by the operator and company user before entering the equipment to site project and to be operated. All equipment conditon must meet to the safety regulation, government regulation
and IKPT SHES Plan.
INSPECTION BY APPROVED BY

Name and Signature Name and Signature

Stiker Number

Stiker Number

Stiker Number

BG-06221IDa2.xlsx
 Security Level 2
BG-06221ID
Appendix (2)-31/89

Form No Form-I-031A
Inspection Date :
MIXER TRUCK Location of Inspection :
Company/Subcontractor :
DAILY CHECK LIST Validty of inspection :
ID NO: MCT - …….
(PER.05/MEN/1985 PESAWAT ANGKAT DAN ANGKUT)
This form must be completed by the operator and leader user before the equipment to be operated. All equipment conditon must meet to the safety regulation, government regulation and IKPT SHES Plan.
INSPECTION Period / / to /
No STANDARDS : / REASON FOR NOT COMPLY
ITEM
Senin Selasa Rabu kamis Jumat Sabtu Minggu
1 Wheel Tire (ban) Not inflatet, as manufacturing standard, forward tire
not vulkanisir(Tidak bocor, kondisi masih aman sesuai
dengan manufacture, roda depan bukan vulkanisir)

2 Fuel tank cover (tutup bahan as manufacturing standard, tight (sesuai dengan standard
bakar) pabrikan, rapat)
3 Fuel tank no leak (tidak bocor)
4 Battery cover (tutup Accu) cover all surface,isolator material ex.rubber (menutupi
seluruh permukaan,matrial isolator ex.karet)
5 Battery cable connections Are tight (rapat)
(sambungan kabel accu)
6 Rearview mirror (kaca spion) clearly (Jelas)
7 Horn (klakson) function (berfungsi)
8 Engine (mesin) No leak, start smootly and no noise (tidak bocor, mudah
dihidupkan dan tidak berisik)
9 Brake (rem) work smootly (berfungsi dengan baik)
10 Headlamp (lampu) as manufacturing standard (sesuai dengan standar
11 Signal, brake, rear lamp Function (berfungsi)
(lampu
sein, rem dan belakang)
12 Reverse Lamp and signal Function (berfungsi)
13 Radiator above min.level, No leak( diatas level min.,tidak bocor)
14 Rotary Lamp Function (berfungsi)
15 Reverse Lamp and signal Function (berfungsi)
16 Hydroulic system (sistem No leaks at all, no noise (tidak bocor, tidak berisik)
hidrolic)
17 No leak at hose and tank Tidak kebocoran di hose dan
Water System tank)
18 No damage and good function (tidak ada rusak dan
Hopper
berfungsi baik)
19 No tearing and working normally (tidak robek dan
Control Cable
berfungsi dengan normal)
20 Roller and Drum No damage and good function (tidak ada rusak dan
berfungsi baik)
21 Fire exthinguser (APAR) Still segel and not expired (bersegel dan tidak kadaluarsa)

22 Safety cone/triangle sign Available (tersedia)

(safety cone/segitiga)
23 First Aid Box Available (tersedia)

OPERATOR
SIGNED BY :
LEADER

REMARKS

BG-06221IDa2.xlsx
 Security Level 2
BG-06221ID
Appendix (2)-31/89

Form No. Form-I-032

Inspection Date :
CONCRETTE PUMP Location of Inspection :
Company/Subcontractor :
INSPECTION STANDARD Validty of inspection :
Type of inspection : Monthly for High Risk/ every 3 Months
(PER.05/MEN/1985 PESAWAT ANGKAT DAN ANGKUT)
This form must be completed by the operator and company user before entering the equipment to site project and to be operated. All equipment conditon must meet to the safety regulation, government regulation
and IKPT SHES Plan.
EQUIPMENT CARRY-IN CERTIFICATE
Type: Police No:
Machine/Engine No: Certificate (STNK) No:
Serial/Plate/Body No.: Certifcate Validity:
Manufacture / Year: Validity Vehicle test by Government (KIR):
Lifting manufacture / Year: Equip. Operation license (SILO/SIA) no.:
Capacity: Equip. Operation license (SILO/SIA) Validity:
Serial Lifting No: Opertor Name:
ID No: CP -……………………. Operator License (SIO) No. :
Operator license (SIO) Validity:
INSPECTION INSPECTION RESULT
No INSPECTION ITEM STANDARDS REASON FOR NOT COMPLY
VISUAL FUNCTION IKPT CLIENT
Common
1 Maintenance record For the pass year is available ●
2 Daily check list For the pass 3 months is available ●
3 Wheel Tire (ban) Not inflatet, as manufacturing standard, forward tire not
vulkanisir(Tidak bocor, kondisi masih aman sesuai dengan ●
manufacture, roda depan bukan vulkanisir)
4 Fuel tank cover (tutup bahan As manufacturing standard, tight (sesuai dengan standard
bakar) pabrikan, rapat)
●
5 Fuel tank No leak (tidak bocor) ●
6 battery cover (tutup Accu) Cover all surface,isolator material ex.rubber (menutupi seluruh
permukaan,matrial isolator ex.karet)
●
7 Rearview mirror (kaca spion) Clearly (Jelas) ●
8 Horn (klakson) Function (berfungsi) ●
9 Engine (mesin) No Leak, Start smootly and no noise (tidak bocor, mudah
dihidupkan dan tidak berisik) ●
10 Brake (rem) Work smootly (berfungsi dengan baik) ●
11 Headlamp (lampu) As manufacturing standard (sesuai dengan standar pabrikasi) ● ●
12 Signal, brake, rear lamp (lampu Function (berfungsi)
sein, rem dan belakang) ● ●
13 Radiator Above min.level,No leak( diatas level min.,tidak bocor) ●
14 Gauge indicator cabin (panel Function (berfungsi)
inidikasi) ●
15 Wiper Function (berfungsi)
●
16 Function (berfungsi)
Rotary Lamp ● ●
17 Function (berfungsi)
Reverse Lamp and signal ● ●
18 Fire exthinguser (APAR) Still segel and not expired (bersegel dan tidak kadaluarsa)
●
19 Safety cone/triangle sign (safety Available (tersedia)
cone/segitiga) ●
20 First aid box Available (tersedia) ●

Special Requirement

1 2 or 4 or more wheel drive Good function (berfungsi dengan baik)

●
2 Hazard symbol (simbol bahaya) Available,readable (tersedia, terbaca)
●
3 Hose/pipe line (slang/pipa) No corrosive,leak,crack (tidak karat,bocor,retak)
● ●
4 Hydroulic system (sistem No leaks at all, no noise (tidak bocor, tidak berisik)
hidrolic) ●
5 Oil hydroulic (oli hidrolic) Above min.level,No leak( diatas level min.,tidak bocor)
●

INSPECTION STATUS
Wiper Rear View Mirror Hydraulic System
PASSED

HOLD

REJECTED

SPECIAL NOTE FROM CLIENT :

INSPECTION BY APPROVED BY
Hydraulic Jack
Tire Fuel Tank
Fog Lamp
Name and Signature Name and Signature
Signal Lamp
Stiker Number

Stiker Number

Stiker Number

BG-06221IDa2.xlsx
 Security Level 2
BG-06221ID
Appendix (2)-
33 /89
Form No Form-I-032A
Inspection Date :
CONCRETTE PUMP Location of Inspection :
Company/Subcontractor :
DAILY CHECK LIST Validty of inspection :
ID No: CP- …..
(PER.05/MEN/1985 PESAWAT ANGKAT DAN ANGKUT)

This form must be completed by the operator and leader user before the equipment to be operated. All equipment conditon must meet to the safety regulation, government regulation and IKPT SHES Plan.
Period: / / to / /
No INSPECTION ITEM STANDARDS Senin Selasa Rabu kamis Jumat Sabtu Minggu REASON FOR NOT COMPLY
1 Wheel Tire (ban) Not inflatet, as manufacturing standard, forward tire not
vulkanisir(Tidak bocor, kondisi masih aman sesuai
dengan manufacture, roda depan bukan vulkanisir)
2 Fuel tank cover (tutup bahan As manufacturing standard, tight (sesuai dengan standard
bakar) pabrikan, rapat)
3 Fuel tank No leak (tidak bocor)
4 battery cover (tutup Accu) Cover all surface,isolator material ex.rubber (menutupi
seluruh permukaan,matrial isolator ex.karet)
5 Battery cable connections Are tight (rapat)
(sambungan kabel accu)
6 Rearview mirror (kaca spion) Clearly (Jelas)
7 Horn (klakson) Function (berfungsi)
8 Engine (mesin) No leak, start smootly and no noise (tidak bocor, mudah
dihidupkan dan tidak berisik)
9 Brake (rem) Work smootly (berfungsi dengan baik)
10 Headlamp (lampu) As manufacturing standard (sesuai dengan standar pabrikasi)
11 Signal, brake, rear lamp (lampu Function (berfungsi)
sein, rem dan belakang)
12 Radiator Above min.level,No leak( diatas level min.,tidak bocor)
13 Gauge indicator cabin (panel Function (berfungsi)
inidikasi)
14 Rotary Lamp Function (berfungsi)

15 Reverse Lamp and signal Function (berfungsi)

16 Hose/pipe line (slang/pipa) No corrosive,leak,crack (tidak karat,bocor,retak)

17 Hydroulic system (sistem No leaks at all, no noise (tidak bocor, tidak berisik)
hidrolic)
18 Oil hydroulic (oli hidrolic) Above min.level,No leak( diatas level min.,tidak bocor)

19 Fire exthinguser (APAR) Still segel and not expired (bersegel dan tidak kadaluarsa)

20 Safety cone/triangle sign (safety Available (tersedia)

cone/segitiga)
21 First aid box Available (tersedia)

OPERATOR
SIGNED BY :
LEADER

REMARKS
Wiper Rear View Mirror Hydraulic System

Fog Lamp
Signal Lamp Tire Hydraulic Jack Fuel Tank

BG-06221IDa2.xlsx
 Security Level 2
BG-06221ID
Appendix (2)-
34 /89
Form no: Form-I-040

PILE DRIVING
Inspection Date :
Location of Inspection :

INSPECTION STANDARD Company/Subcontractor :

Validty of inspection :
(PER.05/MEN/1985 PESAWAT ANGKAT DAN ANGKUT) Type of inspection : Monthly for High Risk/ every 3 Months
This form must be completed by the operator and company user before entering the equipment to site project and to be operated. All equipment conditon must meet to the safety regulation, government regulation and IKPT
SHES Plan.
EQUIPMENT CARRY-IN CERTIFICATE
Type: Police No:
Machine/Engine No: Certificate (STNK) No:
Serial/Plate/Body No.: Certifcate Validity:
Manufacture / Year: Validity Vehicle test by Government (KIR):
Lifting manufacture /Year: Equip. Operation license (SILO/SIA) no.:
Capacity: Equip. Operation license (SILO/SIA) Validity:
Serial Lifting No: Opertor Name:
ID No: CODE PD- ………… Operator License (SIO) No. :
Operator license (SIO) Validity:
Series INSPECTION METHOD INSPECTION RESULT
No INSPECTION ITEM STANDARDS REASON FOR NOT COMPLY
VISUAL FUNCTION IKPT CLIENT
Common
1 Maintenance record For the pass year is available ●
2 Daily check list For the pass 3 months is available ●
3 Main Engine (mesin utama) No abnormal noise,no Leak, easy for start and off, no spark (Tidak
berisik, bocor,mudah di hidup dan matikan, tidak ada percikan api) ● ●

4 Engine starting Easy for start and stop (mudah untuk dinyalakan dan matikan)
●

5 Battery ( Accu ) Have cover by isolator material ex. Rubber,hard plastic( memiliki
●
peutup dari material isolator ex. Karet, plastik yg keras)
6 Fuel tank cover Tight and lock (rapat dan terkunci) ●
7 Radiator No leak (tidak bocor) ●
8 Horn (klakson) Work properly (berfungsi dengan baik) ●
9 Exhaust system (sistem No leak, flame arrestor available and comply with CAP standard(
● ●
buangan/knalpot) tidak
10 Fuel system ( sistem bahan bakar) No leak (tidak bocor) ●
11 Rear view mirrors (kaca spion) As manufacturing standard (sesuai dengan standar pabrikan) ●
12 Windshied wipers Work properly (berfungsi dengan baik) ● `
13 Turning lights ( lampu sein) Work properly (berfungsi dengan baik) ●
14 Stop lights (lampu stop) Work properly (berfungsi dengan baik) ●
15 Rotary Lamp Work properly (berfungsi dengan baik)
16 Reverse lamp and sign (lampu Work properly (berfungsi dengan baik)
mundur dan bel) ● ●
17 Break system (sistem pengereman) Work properly (berfungsi dengan baik) ●
18 Test all function system work properly for all device (semuanya berfungsi dengan baik)
(Electrical/hydrolic) ●

19 Back Mirror Work properly (berfungsi dengan baik) ●

20 Each Side of Windows glasses No crack and clear (tidak retak dan tidak buram) ●
21 Crawler No crack, recondition, bare (tidak retak,rekondisi,gundul) ●
Special Requirement
1 Flame arrestor Available and comply with IKPT standard (terpasang dan sesuai
●
dengan standard IKPT)
2 Fire Extinguisher Fire extinguisher have to install inside cabine operator (Apar harus
●
tersedia di dalam ruangan operator)
3 First Aid Box Available ●
4 Panel Instrument indicator work properly (berfungsi dengan baik) ●
5 boom No bent, rusty and work properly (tidak bengkok, karatan dan
● ●
berfungsi dengan baik)
6 Lead No bent, rusty and Straight (tidak bengkok, karatan dan lurus)
●
7 Brace No bent, rusty and Straight (tidak bengkok, karatan dan lurus)
●
Diesel Hammer
1 ID Code CODE DH- ………… Series
2 Serial No. /Year :
3 Piston Smoothly Function (berfungsi dengan baik) ●
4 Pump Actuator Good function and no leak (Berfunsi dneban baik dan tidak bocor)
● ●

5 Diesel pump Good function and no leak (Berfunsi dneban baik dan tidak bocor)
● ●

6 Exhaust and air inlet Good function and no leak (Berfunsi dneban baik dan tidak bocor)
● ●
7 Injected Fuel Good function and no leak (Berfunsi dneban baik dan tidak bocor)
● ●
Hydraulc Hammer
1 ID Code CODE HH-........................Series
2 Serial No. / Year :
Lifting Hook No Crack (tidak retak)
3 Piston Flod straigth and Work properly (lurus dan berfungsi dengan baik) ● `
4 Ram Housing Clean, no oil spill and no dent (bersih,tidak ada tumpahan minyak `
dan tidak penyok) ●

5 Connectimg rod Good function and hold strongth (Berfunsi dengan baik dan kuat
●
memegang)
6 Piston Smoothly Function (berfungsi dengan baik) ● ●
7 Drive cap cushion No broken (tidak ada yang pecah ●
8 Accumulator No leak,level normal condition >40% (tidak bocor,level normal
● ●
>40%)
9 Hydroulic Cylinder (bulatan hidrolik) No Corrotion, no leak,work and smothly (tidak berkarat, tidak
● ●
bocor,berfungsi dan lancar)

BG-06221IDa2.xlsx
 Security Level 2
BG-06221ID
Appendix (2)-
35 /89
Form no: Form-I-040

PILE DRIVING
Inspection Date :
Location of Inspection :
Company/Subcontractor :
INSPECTION STANDARD Validty of inspection :
Type of inspection : Monthly for High Risk/ every 3 Months
(PER.05/MEN/1985 PESAWAT ANGKAT DAN ANGKUT)
This form must be completed by the operator and company user before entering the equipment to site project and to be operated. All equipment conditon must meet to the safety regulation, government regulation and IKPT
SHES Plan.

INSPECTION STATUS
PASSED

HOLD

REJECTED
Hydraulic Hammer

SPECIAL NOTE FROM CLIENT:

INSPECTION BY APPROVED BY

Name and Signature Name and Signature

Stiker Number

Stiker Number

Stiker Number

BG-06221IDa2.xlsx
 Security Level 2
BG-06221ID
Appendix (2)-
36 /89
Form no: Form-I-040A

PILE DRIVING
Inspection Date :
Location of Inspection :
Company/Subcontractor :
DAILY CHECK LIST Validty of inspection :
ID NO: PD - …….
(PER.05/MEN/1985 PESAWAT ANGKAT DAN ANGKUT)
This form must be completed by the operator and leader user before the equipment to be operated. All equipment conditon must meet to the safety regulation, government regulation and IKPT SHES Plan.
Period: / / to / /
No INSPECTION ITEM STANDARDS REASON FOR NOT COMPLY
Senin Selasa Rabu kamis Jumat Sabtu Minggu
1 Main Engine (mesin utama) No abnormal noise,no Leak, easy for start and off, no spark (Tidak
berisik, bocor,mudah di hidup dan matikan, tidak ada percikan api)

2 Engine Not leak, no noise (tidak bocor,tidak berisik)

3 Battery ( Accu ) Have cover by isolator material ex. Rubber,hard plastic( memiliki
peutup dari material isolator ex. Karet, plastik yg keras)
4 Fuel tank cover Tight and lock (rapat dan terkunci)
5 Radiator No leak (tidak bocor)
6 Horn (klakson) Work properly (berfungsi dengan baik)
7 Exhaust system (sistem No leak, flame arrestor available and comply with CAP standard(
buangan/knalpot) tidak
8 Fuel system ( sistem bahan bakar) No leak (tidak bocor)
9 Rear view mirrors (kaca spion) As manufacturing standard (sesuai dengan standar pabrikan)
10 Turning lights ( lampu sein) Work properly (berfungsi dengan baik)
11 Stop lights (lampu stop) Work properly (berfungsi dengan baik)
12 Rotary Lamp Work properly (berfungsi dengan baik)
13 Reverse lamp and sign (lampu Work properly (berfungsi dengan baik)
mundur dan bel)
14 Break system (sistem pengereman) Work properly (berfungsi dengan baik)
15 Test all function system work properly for all device (semuanya berfungsi dengan baik)
(Electrical/hydrolic)
16 Back Mirror Work properly (berfungsi dengan baik)
17 Crawler No crack, recondition, bare (tidak retak,rekondisi,gundul)

Special Requirement
1 Safety cone/triangle sign (safety Available (tersedia)
cone/segitiga)
2 Fire Extinguisher Fire extinguisher have to install inside cabine operator ( Apar harus
tersedia di dalam ruangan operator )
3 First Aid Box Available
Diesel Hammer
1 ID Code CODE DH.......................Series
2 Serial No. /Year :
3 Pump Actuator Good function and no leak (Berfunsi dneban baik dan tidak bocor)

4 Diesel pump Good function and no leak (Berfunsi dneban baik dan tidak bocor)

5 Exhaust and air inlet Good function and no leak (Berfunsi dneban baik dan tidak bocor)

6 Injected Fuel Good function and no leak (Berfunsi dneban baik dan tidak bocor)

Hydraulc Hammer
1 ID Code CODE HH........................Series
2 Serial No. / Year :
3 Lifting Hook No Crack (tidak retak)
4 Ram Housing Clean, no oil spill and no dent (bersih,tidak ada tumpahan minyak `
dan tidak penyok)
5 Drive cap cushion No broken (tidak ada yang pecah
6 Accumulator No leak,level normal condition >40% (tidak bocor,level normal
>40%)
7 Hydroulic Cylinder (bulatan No Corrotion, no leak,work and smothly (tidak berkarat, tidak
hidrolik) bocor,berfungsi dan lancar)

OPERATOR
SIGNED BY :
LEADER
REMARKS Hydraulic Hammer

BG-06221IDa2.xlsx
 Security Level 2
BG-06221ID
Appendix (2)-
37 /89
Form no. : Form-I- 043
Inspection Date :
BULLDOZER Location of Inspection :
Company/Subcontractor :

INSPECTION STANDARD Validty of inspection :

Seri No. :
Type of inspection : Monthly for High Risk/ every 3 Months
(PER.05/MEN/1985 PESAWAT ANGKAT DAN ANGKUT)
This form must be completed by the operator and company user before entering the equipment to site project and to be operated. All equipment conditon must meet to the safety regulation, government regulation and IKPT
SHES Plan.
EQUIPMENT CARRY-IN CERTIFICATE
Type: Police No:
Machine/Engine No: Certificate (STNK) No:
Serial/Plate/Body No.: Certifcate Validity:
Manufacture / Year: Validity Vehicle test by Government (KIR):
Lifting manufacture / Year: Equip. Operation license (SILO/SIA) no.:
Capacity: Equip. Operation license (SILO/SIA) Validity:
Serial Lifting No: Opertor Name:
ID No: BD- …….. Operator License (SIO) No. :
Operator license (SIO) Validity:
INSPECTION METHOD INSPECTION RESULT
No INSPECTION ITEM STANDARDS REASON FOR NOT COMPLY
VISUAL FUNCTION IKPT CLIENT
Common
1 Maintenance record For the pass year is available ●
2 Daily check list For the pass 3 months is available ●
3 View mirrow Present and clearly (terpasang dan jelas) ● ●
4 Head lamp Work properly ( berfungsi dengan baik) ●
5 Cabin operator assy Clean, instrumentation panel work properly,seat belt
present and work (bersih, panel instrumentasi berfungsi
dengan baik,terdapat sabuk pengaman dan berfungsi) ●

6 Rotary Lamp Work properly ( berfungsi dengan baik) ● ●

7 Reverse lamp and sign Work properly ( berfungsi dengan baik) ● ●
8 Horn Good function (berfungsi dengan baik) ●
9 Data plate Readable (mudah dibaca) ●
10 Warning decals Readable (mudah dibaca) ●
11 Fluid leaks No Fluid leaks under machine (tidak ada cairan ●
yang bocor dibawah mesin)
12 Englne Not leak, no noise (tidak bocor,tidak berisik) ● ●
13 Transmision oil Level corret ●
14 Hydraulic oil Level corret ●
15 Coolent Level corret ●
16 Battery Level correct and caps in place (level benar dan tutup ●
ditempatnya)
17 Park brake Good function (berfungsi dengan baik) ● ●
18 Steering Steers well, no undue noise/stress (setir dengan baik, ● ●
tidak ada suara / stres tidak semestinya)
19 First aid box Available, Minimum 1 box (Ada, minim 1 box) ●
20 FE (Fire Extinguisher) Available, Minimum 1 Bottle (Ada, minim 1 botol) ●
Special Requirement
1 Blade No crack (tidak retak) ●

2 Ripper No crack,moveble ( Tidak retak, bisa digerakkan ● ●

dengan baik)
3 Blade lift Cylender No crack,leak and tight (tidak retak,bocor dan rapat) ● ●

4 Ripper Cylender No crack,leak and tight (tidak retak,bocor dan rapat) ●

5 Cutting edge Not choppy and rusty (Tidak Gompal dan karat) ●

6 Hose Hydraulic to nozzle No crack,Leak (Tidak retak,bocor) ● ●

7 Main hydraulic No leak (tidak bocor) ● ●

8 Hydraulic Pump Work properly, No leak (Bekerja dengan baik, tidak ● ●

bocor)
9 Crawler Tractor Work properly,Tight,No leak at hydraulic ● ●
system(Bekerja dengan baik,rapat,tidak bocor pada
hydraulic sistem)
10 Track rollers and carriers Good condtion, no crack and leaks ● ●
11 Track Good Condition & Tension (kondisi baik dan ● ●
ketegangan)
12 Final Drive Good condition, not chipped and Function smoothly ● ●
(kondisi baik dan tidak gompal dan berfungsi dengan
lancar)
13 Track roller frame Good condition, no crack and no dent (kondisi baik, ● ●
tidak retak dan tidak bengkok)

INSPECTION STATUS

PASSED

HOLD

REJECTED

SPECIAL NOTE FROM CLIENT :

INSPECTION BY APPROVED
BY

Name and Signature Name and Signature

BG-06221IDa2.xlsx
 Security Level 2
BG-06221ID
Appendix (2)-

Form no. : Form-I- 043

38 /89

Inspection Date :
BULLDOZER Location of Inspection :
Company/Subcontractor :

INSPECTION STANDARD Validty of inspection :

Seri No. :
(PER.05/MEN/1985 PESAWAT ANGKAT DAN ANGKUT) Type of inspection : Monthly for High Risk/ every 3 Months
This form must be completed by the operator and company user before entering the equipment to site project and to be operated. All equipment conditon must meet to the safety regulation, government regulation and IKPT
SHES Plan.
Stiker Number

Stiker Number

Stiker Number

BG-06221IDa2.xlsx
 Security Level 2
BG-06221ID
Appendix (2)-
39 /89
Form no. Form-I- 043A
Inspection Date :
BULLDOZER Location of Inspection :
Company/Subcontractor :
DAILY CHECK LIST Validty of inspection :
ID NO: BD - …….
(PER.05/MEN/1985 PESAWAT ANGKAT DAN ANGKUT)
This form must be completed by the operator and leader user before the equipment to be operated. All equipment conditon must meet to the safety regulation, government regulation and IKPT SHES Plan.
Period: / / to / /
No INSPECTION ITEM STANDARDS REASON FOR NOT COMPLY
Senin Selasa Rabu kamis Jumat Sabtu Minggu
1 Head lamp Work properly ( berfungsi dengan baik)
2 Rotary Lamp Work properly ( berfungsi dengan baik)
3 Reverse lamp and sign Work properly ( berfungsi dengan baik)
4 Horn Good function (berfungsi dengan baik)
5 Fluid leaks No Fluid leaks under machine (tidak ada cairan yang bocor
dibawah mesin)
6 Transmision oil Level corret
7 Englne Not leak, no noise (tidak bocor,tidak berisik)
8 Hydraulic oil Level corret
9 Battery Level correct and caps in place (level benar dan tutup
ditempatnya)
10 Battery cable connections Are tight (rapat)
(sambungan kabel accu)
11 Park brake Good function (berfungsi dengan baik)
12 Blade No crack (tidak retak)
13 Ripper No crack,moveble ( Tidak retak, bisa digerakkan dengan baik)

14 Blade lift Cylender No crack,leak and tight (tidak retak,bocor dan rapat)
15 Ripper Cylender No crack,leak and tight (tidak retak,bocor dan rapat)
16 Hose Hydraulic to nozzle No crack,Leak (Tidak retak,bocor)
17 Main hydraulic No leak (tidak bocor)
18 Hydraulic Pump Work properly, No leak (Bekerja dengan baik, tidak bocor)
19 Crawler Tractor Work properly,Tight,No leak at hydraulic system(Bekerja
dengan baik,rapat,tidak bocor pada hydraulic sistem)
20 Track rollers and carriers Good condtion, no crack and leaks
21 Track Good Condition & Tension (kondisi baik dan ketegangan)
22 First aid box Available, Minimum 1 box (Ada, minim 1 box)
23 FE (Fire Extinguisher) Available, Minimum 1 Bottle (Ada, minim 1 botol)

OPERATOR
SIGNED BY :
LEADER

REMARKS

BG-06221IDa2.xlsx
 Security Level 2
BG-06221ID

Appendix (2)-
Form no. : Form-I-044
Inspection Date :
EXCAVATOR Location of Inspection :
Company/Subcontractor :

INSPECTION STANDARD Validty of inspection :

Seri No. :
Type of inspection : Monthly for High Risk/ every 3 Months
(PER.05/MEN/1985 PESAWAT ANGKAT DAN ANGKUT)
This form must be completed by the operator and company user before entering the equipment to site project and to be operated. All equipment conditon must meet to the safety regulation, government regulation and IKPT SHES Plan.
EQUIPMENT CARRY-IN CERTIFICATE
Type: Police No:
Machine/Engine No: Certificate (STNK) No:
Serial/Plate/Body No.: Certifcate Validity:
Manufacture / Year: Validity Vehicle test by Government (KIR):
Lifting manufacture / Year: Equip. Operation license (SILO/SIA) no.:
Capacity: Equip. Operation license (SILO/SIA) Validity:
Serial Lifting No: Opertor Name:
ID No: EX- …….. Operator License (SIO) No. :
Operator license (SIO) Validity:
INSPECTION METHOD INSPECTION RESULT
No INSPECTION ITEM STANDARDS REASON FOR NOT COMPLY
VISUAL FUNCTION IKPT CLIENT
Common
1 Maintenance record For the pass year is available ●
2 Daily check list For the pass 3 months is available ●
3 View mirrow Present and clearly (terpasang dan jelas) ● ●
4 Head lamp Work properly ( berfungsi dengan baik) ●
5 Cabin operator assy Clean, instrumentation panel work properly,seat belt
present and work (bersih, panel instrumentasi berfungsi
●
dengan baik,terdapat sabuk pengaman dan berfungsi)

6 Rotary Lamp Work properly ( berfungsi dengan baik) ● ●

7 Reverse sign Work properly ( berfungsi dengan baik) ● ●
8 Horn Good function (berfungsi dengan baik) ●
9 Data plate Readable (mudah dibaca) ●
10 Warning decals Readable (mudah dibaca) ●
11 Fluid leaks No Fluid leaks under machine (tidak ada cairan yang bocor ●
dibawah mesin)
12 Transmision oil Level corret ●
13 Hydraulic oil Level corret ●
14 Engine Not leak, no noise (tidak bocor,tidak berisik) ●
15 Battery Level correct and caps in place (level benar dan tutup ●
ditempatnya)
16 Park brake Good function (berfungsi dengan baik) ● ●
17 Steering Steers well, no undue noise/stress (setir dengan baik, tidak ● ●
ada suara / stres tidak semestinya)
18 First aid box Available, Minimum 1 box (Ada, minim 1 box) ●
19 FE (Fire Extinguisher) Available, Minimum 1 Bottle (Ada, minim 1 botol) ●
Special Requirement
1 Teeth ( Attachment drawing No: 01 ) No crack (tidak retak) ●
2 Bucket ( Attachment drawing No: 02 ) No crack,moveble ( Tidak retak, bisa digerakkan dengan ● ●
baik)
3 Pin bucket ( Attachment drawing No: 03 ) Present and tight. Not wire (Terpasang dan rapat, bukan ● `
kawat)
4 Angle bucket ( Attachment drawing No: 04 ) Tight,greasing ( rapat, terlumasi) ●
5 Nozzle hydraulic ( Attachment drawing No: 05) No crack,leak and tight (tidak retak,bocor dan rapat) ● ●
6 Hose Hydraulic to nozzle ( Attachment No crack,Leak (Tidak retak,bocor) ● ●
drawing No: 06 )
7 Main hydraulic ( Attachment drawing No: 07 ) No leak (tidak bocor) ● ●
8 ARM ( Attachment drawing No: 08 ) Moveble,No crak and leak (Bisa digerakkan, tidak retak ●
dan bocor)
9 Mash hydraulic ( Attachment drawing No: 09 ) as manufacturing standard (sesuai dengan standar ●
pabrikan)
10 Pump hydraulic ( Attachment drawing No: 11 ) Work properly, No leak (Bekerja dengan baik, tidak bocor) ● ●

11 Crawler ( Attachment drawing No: 13 ) Work properly,Tight,No leak at hydraulic system(Bekerja ● ●

dengan baik,rapat,tidak bocor pada hydraulic sistem)

12 Turn able ( Attachment drawing No: 15 ) Work properly ( berfungsi dengan baik) ● ●

INSPECTION STATUS

PASSED

HOLD

REJECTED

SPECIAL NOTE FROM ClIENT :

INSPECTION BY APPROVED BY

Name and Signature Name and Signature

Stiker Number

Stiker Number

Stiker Number

BG-06221IDa2.xlsx
 Security Level 2
BG-06221ID

Appendix (2)-
Form no. Form-I-044A

EXCAVATOR Inspection Date :

Location of Inspection :
Company/Subcontractor :
DAILY CHECK LIST Validty of inspection :
ID NO: EX - …….
(PER.05/MEN/1985 PESAWAT ANGKAT DAN ANGKUT)
This form must be completed by the operator and leader user before the equipment to be operated. All equipment conditon must meet to the safety regulation, government regulation and IKPT SHES Plan.
Period: / / to / /
No INSPECTION ITEM STANDARDS REASON FOR NOT COMPLY
Senin Selasa Rabu kamis Jumat Sabtu Minggu
1 View mirrow Present and clearly (terpasang dan jelas)
2 Head lamp Work properly ( berfungsi dengan baik)
3 Rotary Lamp Work properly ( berfungsi dengan baik)
4 Reverse sign Work properly ( berfungsi dengan baik)
5 Horn Good function (berfungsi dengan baik)
6 Fluid leaks No Fluid leaks under machine (tidak ada cairan yang bocor
7 Transmision oil Level corret
8 Engine Not leak, no noise (tidak bocor,tidak berisik)
9 Level correct and caps in place (level benar dan tutup
Battery
ditempatnya)
10 Battery cable connections (sambungan Are tight (rapat)
kabel accu)
11 Park brake Good function (berfungsi dengan baik)
12 Steers well, no undue noise/stress (setir dengan baik, tidak
Steering
ada suara / stres tidak semestinya)
13 Teeth (Attachment drawing No: 01) No crack (tidak retak)
14 Bucket (Attachment drawing No: 02) No crack,moveble ( Tidak retak, bisa digerakkan dengan
15 Present and tight. Not wire (Terpasang dan rapat, bukan
Pin bucket (Attachment drawing No:
kawat)
03)
16 Angle bucket (Attachment drawing No: Tight,greasing ( rapat, terlumasi)
04)
17 Nozzle hydraulic (Attachment drawing No crack,leak and tight (tidak retak,bocor dan rapat)
No: 05)
18 Hose Hydraulic to nozzle No crack,Leak (Tidak retak,bocor)
(Attachment drawing No: 06)
19 Main hydraulic (Attachment drawing No leak (tidak bocor)
No: 07)
20 ARM (Attachment drawing No: 08) Moveble,No crak and leak (Bisa digerakkan, tidak retak
dan
21 Hydraulic Pump (Attachment drawing Work properly, No leak (Bekerja dengan baik, tidak bocor)
No: 11)
22 Crawler (Attachment drawing No: 13) Work properly,Tight,No leak at hydraulic system(Bekerja
23 Work properly ( berfungsi dengan baik)
Turn able (Attachment drawing No: 15)
24 First aid box Available, Minimum 1 box (Ada, minim 1 box)
25 FE (Fire Extinguisher) Available, Minimum 1 Bottle (Ada, minim 1 botol)

OPERATOR
SIGNED BY :
LEADER

REMARKS

BG-06221IDa2.xlsx
 Security Level 2
BG-06221ID

Appendix (2)-
Form no.: Form-I-045
Inspection Date :
LOADDER Location of Inspection :
Company/Subcontractor :

INSPECTION STANDARD Validty of inspection :

Type of inspection : Monthly for High Risk/ every 3 Months
(PP/No.50/2012)
This form must be completed by the operator and company user before entering the equipment to site project and to be operated. All equipment conditon must meet to the safety regulation, government regulation and IKPT
SHES Plan.
EQUIPMENT CARRY-IN CERTIFICATE
Type: Police No:

Machine/Engine No: Certificate (STNK) No:

Serial/Plate/Body No.: Certifcate Validity:

Manufacture / Year: Validity Vehicle test by Government (KIR):

Lifting manufacture / Year: Equip. Operation license (SILO/SIA) no.:

Capacity: Equip. Operation license (SILO/SIA) Validity:

Serial Lifting No: Opertor Name:

ID No: LD- …….. Operator License (SIO) No. :

Operator license (SIO) Validity:
INSPECTION METHOD INSPECTION RESULT
No INSPECTION ITEM STANDARDS VISUAL FUNCTION IKPT CLIENT REASON FOR NOT COMPLY
Common

1 Maintenance record For the pass year is available ●

2 Daily check list For the pass 3 months is available ●

3 Wheel tire Not inflated,as manufacturing using guide standard,nut tights ●

(tidak kempes,sesuai dengan petunjuk penggunaan dari
4 Head,signal lamp Work (berfungsi) ● ●
5 Rotary Lamp Work (berfungsi) ● ●
6 reverse lamp and signal Work (berfungsi) ● ●
7 Wiper Work (berfungsi) ●
8 Radiator No leak and level coalant as per standard (tidak bocor dan
level air pendingin sesuai standar) ●

9 Cabin panel Work (berfungsi) ●

10 Fuel oil Not leak (tidak bocor) ●
11 Fuel cap tank/reservoir As manufacturing standard (sesuai dengan standar pabrikan) ●
12 Driver cabin clean,free from oil spill (bersih,tidak ada tumpahan oli) ●
13 Engine Not leak, no noise (tidak bocor,tidak berisik) ● ●
14 Brake Not leak, Good function (tidak bocor, berfungsi dengan baik) ● ●
15 Engine switch Work (berfungsi) ● `
16 Battrey/accu Cover surface with isolator material ex.rubber (menutupi ●
permukaan aki
17 First aid kit available 1 box (ada 1 box) ●
18 Fire extinguisher Available minimum 1 botte (ada minimum 1 botol) ●
Special Requirement

1 Crawler (if used) not leak at hydraulic system,connection tights (tidak bocor ● ●
pada sistem
2 Cabin roof made from hard cover ex. Metal plate and covering surface ●
(terbuat dari
3 Loadder bucket not crack (tidak retak) ●
4 Loadder teeth (*if any) not crack (tidak retak) ●
5 Hydraulic system not leak (tidak bocor) ●
6 Boom lift not abrasive,crack (tidak abrasif,retak) ●
7 Bucket Links tight,not leak (rapat,tidak bocor) ● ●
8 Booms not abrasive,crack (tidak abrasif,retak) ● ●
9 Bucket tilt cylinders tight,not leak (rapat,tidak bocor) ● ●
10 Steering cylenders tight,not leak (rapat,tidak bocor) ● ●
11 Axle tight,not leak (rapat,tidak bocor) ● ●
12 Ladder not crack (tidak retak) ●

INSPECTION STATUS
PASSED

HOLD

REJECTED

SPECIAL NOTE FROM CLIENT :

INSPECTION BY APPROVED BY

Name and Signature Name and Signature

Stiker Number

Stiker Number

Stiker Number

BG-06221IDa2.xlsx
 Security Level 2
BG-06221ID

Appendix (2)-
Form no.: Form-I-045A
Inspection Date :
LOADDER Location of Inspection :
Company/Subcontractor :
DAILY CHECK LIST Validty of inspection :
ID NO: LD - …….
(PP/No.50/2012)
This form must be completed by the operator and leader user before the equipment to be operated. All equipment conditon must meet to the safety regulation, government regulation and IKPT SHES Plan.
Period / / to / /
No INSPECTION ITEM STANDARDS : REASON FOR NOT COMPLY
Senin Selasa Rabu kamis Jumat Sabtu Minggu
1 Wheel tire Not inflated,as manufacturing using guide standard,nut
tights (tidak kempes,sesuai dengan petunjuk
penggunaan
dari pabrikan)
2 Head,signal lamp Work (berfungsi)
3 Rotary Lamp Work (berfungsi)
4 Reverse lamp and signal Work (berfungsi)
5 Wiper Work (berfungsi)
6 Radiator No leak and level coalant as per standard (tidak bocor dan
level air pendingin sesuai standar)
7 Cabin panel Work (berfungsi)
8 Fuel oil Not leak (tidak bocor)
9 Engine Not leak, no noise (tidak bocor,tidak berisik)
10 Brake Not leak, Good function (tidak bocor, berfungsi dengan
11 Battrey/accu Cover surface with isolator material ex.rubber (menutupi
permukaan aki dengan material isolator ex.karet)

12 Battery cable connections Are tight (rapat)

(sambungan kabel accu)
13 Crawler (if used) not leak at hydraulic system,connection tights (tidak bocor
pada sistem
14 Loadder bucket not crack (tidak retak)
15 Loadder teeth (*if any) not crack (tidak retak)
16 Hydraulic system not leak (tidak bocor)
17 Boom lift not abrasive,crack (tidak abrasif,retak)
18 Bucket Links tight,not leak (rapat,tidak bocor)
19 Bucket tilt cylinders tight,not leak (rapat,tidak bocor)
20 Steering cylenders tight,not leak (rapat,tidak bocor)
21 Axle tight,not leak (rapat,tidak bocor)
22 First aid kit available 1 box (ada 1 box)
23 Fire extinguisher Available minimum 1 botte (ada minimum 1 botol)

OPERATOR
SIGNED BY :
LEADER
REMARKS

BG-06221IDa2.xlsx
 Security Level 2
BG-06221ID

Appendix (2)-
Form no. : Form-I- 046
Inspection Date :
GRADER/RIPPER Location of Inspection :
Company/Subcontractor :
INSPECTION STANDARD Validty of inspection :
Seri No. :
Type of inspection : Monthly for High Risk/ every 3 Months
(PER.05/MEN/1985 PESAWAT ANGKAT DAN ANGKUT)
This form must be completed by the operator and company user before entering the equipment to site project and to be operated. All equipment conditon must meet to the safety regulation, government regulation and IKPT
SHES Plan.
EQUIPMENT CARRY-IN CERTIFICATE
Type: Police No:
Machine/Engine No: Certificate (STNK) No:
Serial/Plate/Body No.: Certifcate Validity:
Manufacture / Year: Validity Vehicle test by Government (KIR):
Lifting manufacture / Year: Equip. Operation license (SILO/SIA) no.:
Capacity: Equip. Operation license (SILO/SIA) Validity:
Serial Lifting No: Opertor Name:
ID No: GR/RP- …….. Operator License (SIO) No. :
Operator license (SIO) Validity:
INSPECTION METHOD INSPECTION RESULT
No INSPECTION ITEM STANDARDS REASON FOR NOT COMPLY
VISUAL FUNCTION IKPT CLIENT
Common
1 Maintenance record For the pass year is available ●
2 Daily check list For the pass 3 months is available ●
3 View mirrow Present and clearly (terpasang dan jelas) ● ●
4 Head lamp Work properly ( berfungsi dengan baik) ●
5 Cabin operator assy Clean, instrumentation panel work properly,seat belt
present and work (bersih, panel instrumentasi
berfungsi dengan baik,terdapat sabuk pengaman dan ●
berfungsi)
6 Rotary Lamp Work properly ( berfungsi dengan baik) ● ●
7 Reverse lamp and sign Work properly ( berfungsi dengan baik) ● ●
8 Horn Good function (berfungsi dengan baik) ●
9 Data plate Readable (mudah dibaca) ●
10 Warning decals Readable (mudah dibaca) ●
11 Engine No Fluid leaks under machine (tidak ada cairan yang ●
bocor dibawah mesin)
12 Transmision oil Level corret ●
13 Hydraulic oil Level corret ●
14 Coolent Level corret ●
15 Battery Level correct and caps in place (level benar dan tutup ●
ditempatnya)
16 Park brake Good function (berfungsi dengan baik) ● ●
17 Steering Steers well, no undue noise/stress (setir dengan baik, tidak ● ●
ada suara / stres tidak semestinya)
18 First aid box Available, Minimum 1 box (Ada, minim 1 box) ●
19 FE (Fire Extinguisher) Available, Minimum 1 Bottle (Ada, minim 1 botol) ●
Special Requirement
1 Blade No crack (tidak retak) ●

2 Ripper No crack,moveble ( Tidak retak, bisa digerakkan ● ●

dengan baik)
3 Blade circle shoes No crack,leak and tight (tidak retak,bocor dan rapat) ● ●

4 Ripper Cylender No crack,leak and tight (tidak retak,bocor dan rapat) ●

5 Ball and sockets Not noise and rusty (Tidak bising dan karat) ●

6 Hose Hydraulic to nozzle No crack,Leak (Tidak retak,bocor) ● ●

7 Main hydraulic No leak (tidak bocor) ● ●

8 Pump hydraulic Work properly, No leak (Bekerja dengan baik, tidak ● ●

bocor)
9 Front wheel spindle bearing housing Good condtion, no crack and leaks ● ●

10 Tire Good damage & excessive wear (tidak rusak dan haus) ● ●

11 Final Drive Good condition, not chipped and Function smoothly ● ●

(kondisi baik dan tidak gompal dan berfungsi
dengan
lancar)
12 Tandem Hoausing Good condition, no crack and no leaks (kondisi baik, tidak ● ●
retak dan tidak bocor)
13 Step ladder Good condition and cleane (kondisi baik dan bersih)

INSPECTION STATUS

PASSED

HOLD

REJECTED

SPECIAL NOTE FROM CLIENT :

INSPECTION BY APPROVED
BY

Name and Signature Name and Signature

BG-06221IDa2.xlsx
 Security Level 2
BG-06221ID

Appendix (2)-
Form no. : Form-I- 046

GRADER/RIPPER Inspection Date :

Location of Inspection :

INSPECTION STANDARD Company/Subcontractor :

Validty of inspection :
Seri No. :
(PER.05/MEN/1985 PESAWAT ANGKAT DAN ANGKUT) Type of inspection : Monthly for High Risk/ every 3 Months
This form must be completed by the operator and company user before entering the equipment to site project and to be operated. All equipment conditon must meet to the safety regulation, government regulation and IKPT
SHES Plan.
Stiker Number

Stiker Number

Stiker Number

BG-06221IDa2.xlsx
 Security Level 2
BG-06221ID

Appendix (2)-
Form no. Form-I- 046A
Inspection Date :
GRADER/RIPPER Location of Inspection :
Company/Subcontractor :

DAILY CHECK LIST Validty of inspection :

Seri No. :
ID NO: GR/RP - …….
(PER.05/MEN/1985 PESAWAT ANGKAT DAN ANGKUT)
This form must be completed by the operator and leader user before the equipment to be operated. All equipment conditon must meet to the safety regulation, government regulation and IKPT SHES Plan.
Period: / / to / /
No INSPECTION ITEM STANDARDS REASON FOR NOT COMPLY
Senin Selasa Rabu kamis Jumat Sabtu Minggu
1 View mirrow Present and clearly (terpasang dan jelas)
2 Head lamp Work properly ( berfungsi dengan baik)
3 Rotary Lamp Work properly ( berfungsi dengan baik)
4 Reverse lamp and sign Work properly ( berfungsi dengan baik)
5 Horn Good function (berfungsi dengan baik)
6 Engine No Fluid leaks under machine (tidak ada
cairan yang bocor dibawah mesin)
7 Transmision oil Level corret
8 Battery Level correct and caps in place (level benar dan
tutup ditempatnya)
9 Park brake Good function (berfungsi dengan baik)
10 Steering Steers well, no undue noise/stress (setir dengan
baik, tidak ada suara / stres tidak semestinya)
11 First aid box Available, Minimum 1 box (Ada, minim 1 box)
12 FE (Fire Extinguisher) Available, Minimum 1 Bottle (Ada, minim 1
13 Blade No crack (tidak retak)

14 Ripper No crack,moveble ( Tidak retak, bisa

digerakkan dengan baik)
15 Blade circle shoes No crack,leak and tight (tidak retak,bocor dan
rapat)
16 Ripper Cylender No crack,leak and tight (tidak retak,bocor dan
rapat)
17 Hose Hydraulic to nozzle No crack,Leak (Tidak retak,bocor)
18 Pump hydraulic Work properly, No leak (Bekerja dengan baik,
tidak bocor)
19 Tire Good damage & excessive wear (tidak rusak dan
haus)
20 First aid box Available, Minimum 1 box (Ada, minim 1 box)
21 FE (Fire Extinguisher) Available, Minimum 1 Bottle (Ada, minim 1
botol)

OPERATOR
SIGNED BY :
LEADER
REMARKS

BG-06221IDa2.xlsx
 Security Level 2
BG-06221ID

Appendix (2)-
Formno.: Form-I-047

VIBRATOR ROLLER
Inspection Date :
Location of Inspection :

INSPECTION STANDARD Company/Subcontractor :

Validty of inspection :
(PER.05/MEN/1985 PESAWAT ANGKAT DAN ANGKUT) Type of inspection : Monthly for High Risk/ every 3 Months
This form must be completed by the operator and company user before entering the equipment to site project and to be operated. All equipment conditon must meet to the safety regulation, government regulation
and IKPT SHES Plan.
EQUIPMENT CARRY-IN CERTIFICATE
Type: Police No:
Machine/Engine No: Certificate (STNK) No:
Serial/Plate/Body No.: Certifcate Validity:
Manufacture / Year: Validity Vehicle test by Government (KIR):
Lifting manufacture /Year: Equip. Operation license (SILO/SIA) no.:
Capacity: Equip. Operation license (SILO/SIA) Validity:
Serial Lifting No: Opertor Name:
ID No: VB - …….. Operator License (SIO) No. :
Operator license (SIO) Validity:
INSPECTION METHOD INSPECTION RESULT
No INSPECTION ITEM STANDARDS REASON FOR NOT COMPLY
VISUAL FUNCTION IKPT CLIENT
Common
1 Maintenance record For the pass year is available ●
2 Daily check list For the pass 3 months is available ●
3 Main Engine Main engine runing with normal such as : ( A ) Don't hight noise, (
B ) Don't out much smoke from knalpot ( Mesin utam berputar
dengan normal seperti : ( A ) Tidak berisik / Tidak mengeluarkan ● ●
punyi yang keras ( B ) Tidak mengeluarkan banyak asap dari
knapot
4 Motor starting Turn ON and OFF function with well ( Kunci kontak hidup dam
mati mesin berfungsi dengan baik ) ●
5 Battery ( Accu ) Battery ( Accu ) have to cover by ruber ( Accu harus dilindungi
dengan ●
6 Fuel tank cover Fuel tank have to cover ( Tutup tanki bahan bakar harus tertutup
dengan rapih / baik ) ●
7 Cooling system radiator Cooling system radiator don't leak ( Sistem pendinginan tidak
bocor ) ●
8 Horn Horn have to sound ( Klatson harus berfungsi / berbunyi)
●
9 Exhaust system No leak in exhaust system (Tidak bocor pada sistim exhaust)
● ●
10 Sparks exist on engine No sparks exist on engine ( Tidak ada spark yang keluar dari mesin
) ● ●
11 Fuel system No leak in fuel system ( Tidak ada kebocoran di sistem bahan `
bakar ) ● ●
12 Windshied wipers (10) Installed and well function (terpasang dan berfungsi dengan baik)
●
13 Break system Break system have to function with well ( Rem harus berfungsi
dengan baik ) ●
14 Head Lamp (11) Lampu Utama dalam kondisi baik dan berfungsi (Head lamp is
good condition and no break) ● ●
15 Drive cabin (12) Ruangan operator dalam kondisi baik (Drive cabin is good
condition) ●
16 Rotary lamp Available and good function (ada dan berfunsi baik)

17 Reverse lamp and sign Available and good function (ada dan berfunsi baik)
● ●
18 FE (Fire extinghuiser) Available minimum 1 Botle (ada minimum 1 botol)
●
19 Fist aid box Available minimum 1box (ada minimum 1 box)
●
Special Requirement
1 Flame arrestor Flame arrestor have to install for break spark form klanpot
(Pemecah api harus terpasang di ujung knalpot ) ● ●
2 Roller Vibro (1) Roller atau roda depan harus berfungsi dengan baik ( Roller or
front of wheel must function of proper ) ●
3 Head Vibro (2) Head vibro harus tidak retak ( Head vibro not break ) ●
4 Pin Vibro or Connector hose Jarum dan hose hydraulic terpasang dengan baik (Pin and hose
hydraulic (3) connector hydraulic of proper ) ●
5 Hose Hyraulic (4) Hose hyraulic tidak bocor atau retak ( Hose hydraulic not leak and
break) ● ●
6 Hand rail (5) Hand rail menuju ke cabin operator harus baik ( hand rail to cabine
operator must proper ) ●
7 Ladder (6) Tangga dalam keadaan baik tidak retak ( Leadder must proper and
No break ) ●
8 Main / Mechine hydraulic (7) Main hydraulic don't leak ( hydraulic utama tidak boleh bocor )
●
9 Streering or front wheel (8) Roda ban tidak retak ( Streeng no break )
●
10 Mechine Vibro (9) Mesin hydraulic dalam kondisi baik dan tidak bocor ( Mechine
good condition and no leak ) ● ●
11 Tire Good damage & excessive wear (tidak rusak dan haus) ●
12 Test all function system Have to test all function system ( Harus dicoba semua sistem yang
berfungsi ) ●

BG-06221IDa2.xlsx
 Security Level 2
BG-06221ID

Appendix (2)-
Formno.: Form-I-047
Inspection Date :
VIBRATOR ROLLER Location of Inspection :
Company/Subcontractor :
INSPECTION STANDARD Validty of inspection :
Type of inspection : Monthly for High Risk/ every 3 Months
(PER.05/MEN/1985 PESAWAT ANGKAT DAN ANGKUT)
This form must be completed by the operator and company user before entering the equipment to site project and to be operated. All equipment conditon must meet to the safety regulation, government regulation
and IKPT SHES Plan.
INSPECTION STATUS (12)
PASSED (11)

HOLD (10) (9)

REJECTED (1)
(7)

SPECIAL NOTE FROM CLIENT:

(8)

(2)
INSPECTIO APPROVED BY (6)

(3) (4) (5)

Name and Name and Signature
Stiker Number

Stiker Number

Stiker Number

BG-06221IDa2.xlsx
 Security Level 2
BG-06221ID

Appendix (2)-
Formno.: Form-I-047A

VIBRATOR ROLLER
Inspection Date :
Location of Inspection :
Company/Subcontractor :
DAILY CHECK LIST Validty of inspection :
ID NO: VB - …….
(PER.05/MEN/1985 PESAWAT ANGKAT DAN ANGKUT)
This form must be completed by the operator and leader user before the equipment to be operated. All equipment conditon must meet to the safety regulation, government regulation and IKPT SHES Plan.
Period: / / to / /
No INSPECTION ITEM STANDARDS Senin Selasa Rabu kamis Jumat Sabtu Minggu REASON FOR NOT COMPLY
1 Main Engine Main engine runing with normal
2 Battery ( Accu ) Battery ( Accu ) have to cover by ruber ( Accu harus
dilindungi menggunakan karet )
3 Battery cable connections Are tight (rapat)
(sambungan kabel accu)
4 Fuel tank cover Fuel tank have to cover ( Tutup tanki bahan bakar harus
tertutup dengan rapih / baik )
5 Fuel system No leak in fuel system ( Tidak ada kebocoran di sistem
bahan bakar )
6 Cooling system radiator Cooling system radiator don't leak ( Sistem pendinginan
tidak bocor )
7 Horn Horn have to sound ( Klatson harus berfungsi / berbunyi)

8 Windshied wipers (10) Installed and well function (terpasang dan berfungsi
dengan baik)
9 Break system Break system have to function with well ( Rem harus
berfungsi dengan baik )
10 Head Lamp (11) Lampu Utama dalam kondisi baik dan berfungsi ( Head
lamp is good condition and no break )
11 Rotary lamp Available and good function (ada dan berfunsi baik)

12 Reverse lamp and sign Available and good function (ada dan berfunsi baik)

13 Roller Vibro (1) Roller atau roda depan harus berfungsi dengan baik (
Roller or front of wheel must function of proper )
14 Head Vibro (2) Head vibro harus tidak retak ( Head vibro not break )
15 Pin Vibro or Connector hose Jarum dan hose hydraulic terpasang dengan baik (Pin and
hydraulic (3) hose connector hydraulic of proper )
16 Hose Hyraulic (4) Hose hyraulic tidak bocor atau retak ( Hose hydraulic not
leak and break)
17 Main / Mechine hydraulic (7) Main hydraulic don't leak ( hydraulic utama tidak boleh
bocor )
18 Streering or front wheel (8) Roda ban tidak retak ( Streeng no break )

19 Mechine Vibro (9) Mesin hydraulic dalam kondisi baik dan tidak bocor (
Mechine good condition and no leak )
20 Tire Good damage & excessive wear (tidak rusak dan haus)

21 FE (Fire extinghuiser) Available minimum 1 Botle (ada minimum 1 botol)

22 Fist aid box Available minimum 1box (ada minimum 1 box)

REMARKS (12)
(11)

(10) (9)

(1) (7)

(8)

(2)
(6)

(3) (4) (5)

BG-06221IDa2.xlsx
 Security Level 2
BG-06221ID

Appendix (2)-

Form no. : Form-I-048

Inspection Date :
POWER SHOVEL Location of Inspection :

INSPECTION STANDARD
Company/Subcontractor :
Validty of inspection :
Seri No. :
(PER.05/MEN/1985 PESAWAT ANGKAT DAN ANGKUT) Type of inspection : Monthly for High Risk/ every 3 Months
This form must be completed by the operator and company user before entering the equipment to site project and to be operated. All equipment conditon must meet to the safety regulation, government regulation and IKPT
SHES Plan.
EQUIPMENT CARRY-IN CERTIFICATE
Type: Police No:
Machine/Engine No: Certificate (STNK) No:
Serial/Plate/Body No.: Certifcate Validity:
Manufacture / Year: Validity Vehicle test by Government (KIR):
Lifting manufacture / Year: Equip. Operation license (SILO/SIA) no.:
Capacity: Equip. Operation license (SILO/SIA) Validity:
Serial Lifting No: Opertor Name:
ID No: PS - …….. Operator License (SIO) No. :
Operator license (SIO) Validity:
INSPECTION METHOD INSPECTION RESULT
No INSPECTION ITEM STANDARDS REASON FOR NOT COMPLY
VISUAL FUNCTION IKPT CLIENT
Common
1 Maintenance record For the pass year is available ●
2 Daily check list For the pass 3 months is available ●
3 Main Engine Main engine runing with normal such as : ( A ) Don't
hight noise, ( B ) Don't out much smoke from knalpot
( Mesin utam berputar dengan normal seperti : ( A ) ● ●
Tidak berisik / Tidak mengeluarkan punyi yang keras ( B
) Tidak
mengeluarkan banyak asap dari knapot)
4 Motor starting Turn ON and OFF function with well ( Kunci kontak
hidup dam mati ●
5 Battery Level correct and caps in place (level benar dan tutup
ditempatnya) ●
6 View mirrow Present and clearly (terpasang dan jelas)
● ●
7 Head lamp Work properly ( berfungsi dengan baik) ●
8 Cabin operator assy Clean, instrumentation panel work properly,seat belt
present and work (bersih, panel instrumentasi berfungsi
dengan baik,terdapat sabuk pengaman dan berfungsi) ●

9 Rotary Lamp Work properly ( berfungsi dengan baik) ● ●

10 Reverse sign Work properly ( berfungsi dengan baik) ● ●
11 Horn Good function (berfungsi dengan baik) ● ●
12 Data plate Readable (mudah dibaca) ●
13 Warning decals Readable (mudah dibaca) ●
14 Fluid leaks No Fluid leaks under machine (tidak ada cairan yang bocor
dibawah mesin) ●
15 Transmision oil Level corret ●
16 Hydraulic oil Level corret ●
17 Coolent Level corret ●
18 Park brake Good function (berfungsi dengan baik) ● ●
19 Steering Steers well, no undue noise/stress (setir dengan baik, tidak
ada suara / stres tidak semestinya) ● ●
20 First aid box Available, Minimum 1 box (Ada, minim 1 box) ●
21 FE (Fire Extinguisher) Available, Minimum 1 Bottle (Ada, minim 1 botol) ●
Special Requirement ●
1 Bucket No crack,moveble ( Tidak retak, bisa digerakkan dengan
baik) ●
2 Crowd cable No damage and rusty ( Tidak rusak dan karat)
●
3 Stick No crack and dent (tidak retak dan penyok) `
●
4 Hoist cable no damage, Tight, greasing (tidak rusak rapat, terlumasi)
●
5 Boom No crack and dent (tidak retak dan penyok)
●
6 Support cable no damage, Tight, greasing (tidak rusak rapat, terlumasi)
●
7 Saddle block good function and no noise (berfungsi dengan baik dan
tidak bising) ● ●
8 A-Frame No crack and bent (tidak retak dan bengkok)
●
9 Crawler Work properly,Tight,No leak at hydraulic system(Bekerja
dengan baik,rapat,tidak bocor pada hydraulic sistem) ● ●
10 Turn able Work properly ( berfungsi dengan baik)
● ●

BG-06221IDa2.xlsx
 Security Level 2
BG-06221ID

Appendix (2)-

Form no. : Form-I-048

Inspection Date :
POWER SHOVEL Location of Inspection :
Company/Subcontractor :

INSPECTION STANDARD Validty of inspection :

Seri No. :
Type of inspection : Monthly for High Risk/ every 3 Months
(PER.05/MEN/1985 PESAWAT ANGKAT DAN ANGKUT)
This form must be completed by the operator and company user before entering the equipment to site project and to be operated. All equipment conditon must meet to the safety regulation, government regulation and IKPT
SHES Plan.

INSPECTION STATUS

PASSED

HOLD

REJECTED

SPECIAL NOTE FROM CLIENT :

INSPECTION APPROVED BY
BY

Name and Signature Name and Signature

Stiker Number

Stiker Number

Stiker Number

BG-06221IDa2.xlsx
 Security Level 2
BG-06221ID

Appendix (2)-
Form no. Form-I-048A

POWER SHOVEL Inspection Date :

Location of Inspection :

DAILY CHECK LIST

Company/Subcontractor :
Validty of inspection :
(PER.05/MEN/1985 PESAWAT ANGKAT DAN ANGKUT) ID NO: PS - …….

This form must be completed by the operator and leader user before the equipment to be operated. All equipment conditon must meet to the safety regulation, government regulation and IKPT SHES Plan.
Period: / / to / /
No INSPECTION ITEM STANDARDS Senin Selasa Rabu kamis Jumat Sabtu Minggu REASON FOR NOT COMPLY

1 Main Engine Main engine runing with normal

Battery ( Accu ) Battery ( Accu ) have to cover by ruber ( Accu harus
2
dilindungi menggunakan karet )
Battery cable connections Are tight (rapat)
3
(sambungan kabel accu)
4 View mirrow Present and clearly (terpasang dan jelas)
5 Head lamp Work properly ( berfungsi dengan baik)
6 Rotary Lamp Work properly ( berfungsi dengan baik)
7 Reverse sign Work properly ( berfungsi dengan baik)
8 Horn Good function (berfungsi dengan baik)
Fluid leaks No Fluid leaks under machine (tidak ada cairan yang
9 bocor dibawah mesin)
10 Transmision oil Level corret
11 Hydraulic oil Level corret
12 Coolent Level corret
13 Park brake Good function (berfungsi dengan baik)
Steering Steers well, no undue noise/stress (setir dengan baik,
14
tidak ada suara / stres tidak semestinya)
Bucket No crack,moveble ( Tidak retak, bisa digerakkan
15 dengan baik)
16 Crowd cable No damage and rusty ( Tidak rusak dan karat)

Stick No crack and dent (tidak retak dan penyok) `

17
Hoist cable no damage, Tight, greasing (tidak rusak rapat,
18 terlumasi)
Support cable no damage, Tight, greasing (tidak rusak rapat,
19
terlumasi)
Saddle block good function and no noise (berfungsi dengan baik
20
dan tidak bising)
21 A-Frame No crack and bent (tidak retak dan bengkok)

Crawler Work properly,Tight,No leak at hydraulic

22 system(Bekerja dengan baik,rapat,tidak bocor pada
hydraulic sistem)
23 First aid box Available, Minimum 1 box (Ada, minim 1 box)
24 FE (Fire Extinguisher) Available, Minimum 1 Bottle (Ada, minim 1 botol)

REMARKS

BG-06221IDa2.xlsx
 Security Level 2
BG-06221ID

Appendix (2)-
Form no: Form-I-049
Inspection Date :
DRAG-LINE / CLAMSHELL Location of Inspection :
Company/Subcontractor :
INSPECTION STANDARD Validty of inspection :
Type of inspection : Monthly for High Risk/ every 3 Months
(PER.05/MEN/1985 PESAWAT ANGKAT DAN ANGKUT)
This form must be completed by the operator and company user before entering the equipment to site project and to be operated. All equipment conditon must meet to the safety regulation, government regulation and IKPT
SHES Plan.
EQUIPMENT CARRY-IN CERTIFICATE
Type: Police No:
Machine/Engine No: Certificate (STNK) No:
Serial/Plate/Body No.: Certifcate Validity:
Manufacture / Year: Validity Vehicle test by Government (KIR):
Lifting manufacture / Year: Equip. Operation license (SILO/SIA) no.:
Capacity: Equip. Operation license (SILO/SIA) Validity:
Serial Lifting No: Opertor Name:
ID No: DL/CS- …….. Operator License (SIO) No. :
Operator license (SIO) Validity:
INSPECTION METHOD INSPECTION RESULT
No INSPECTION ITEM STANDARDS REASON FOR NOT COMPLY
VISUAL FUNCTION IKPT CLIENT
Common
1 Maintenance record For the pass year is available ●
2 Daily check list For the pass 3 months is available ●
3 Main Engine (mesin utama) No abnormal noise, no Leak, easy for start and off, no spark
(Tidak berisik, bocor,mudah di hidup dan matikan, tidak ● ●
ada percikan api)
4 Engine starting Easy for start and stop (mudah untuk dinyalakan dan matikan) ●
5 Battery ( Accu ) Have cover by isolator material ex. Rubber,hard plastic( memiliki
●
peutup dari material isolator ex. Karet, plastik yg keras)
6 Fuel tank cover Tight and lock (rapat dan terkunci) ●
7 Radiator No leak (tidak bocor) ●
8 Horn (klakson) Work properly (berfungsi dengan baik) ●
9 Exhaust system (sistem No leak, flame arrestor available and comply with CAP standard(
● ●
buangan/knalpot) tidak
10 Fuel system ( sistem bahan bakar) No leak (tidak bocor) ●
11 Rear view mirrors (kaca spion) As manufacturing standard (sesuai dengan standar pabrikan) ●
12 Windshied wipers Work properly (berfungsi dengan baik) ● `
13 Stop lights (lampu stop) Work properly (berfungsi dengan baik) ●
14 Rotary Lamp Work properly (berfungsi dengan baik)
15 Reverse lamp and sign (lampu Work properly (berfungsi dengan baik)
mundur dan bel) ● ●
16 Break system (sistem pengereman) Work properly (berfungsi dengan baik) ●
17 Test all function work properly for all device (semuanya berfungsi dengan baik)
system ●
(Electrical/hydrolic)
18 Back Mirror Work properly (berfungsi dengan baik) ●
19 Each Side of Windows glasses No crack and clear (tidak retak dan tidak buram) ●
20 Crawler No crack, recondition, bare (tidak retak,rekondisi,gundul) ●
21 Fire extinguisher Available (ada) ●
22 First Aid Box Available (ada) ●
Special Requirement
1 Dragline/clampshell No crack and work properly (tidak retak dan berfungsi dengan
baik) ●
2 Hoist chain No broken, rusty and crack of chain (tidak rusak, karat dan retak)
● ●
utama )
3 Dump rope No damage and rusty (tidak rusak dan karatan) ●
4 Boom No bent, rusty and work properly (tidak bengkok, karatan dan
berfungsi dengan baik) ●
5 Boom point sheave Work properly (berfungsi dengan baik) ●
6 Drag chain No broken and crack of chain (tidak rantai putus dan retak) ●
7 Hoist rope No damage and rusty(tidak rusak dan karatan) ●
8 Bridge support rope No damage and rusty(tidak rusak dan karatan) ● `
9 Mast No bent, rusty and work properly (tidak bengkok, karatan dan `
●
berfungsi dengan baik)
10 Boom rest No crack and work properly (tidak retak dan berfungsi
dengan baik) ● ●
11 Driver cabin assy Clean, no oil spill (bersih,tidak ada tumpahan minyak) ●
12 A-Frame No bent, rusty and work properly (tidak bengkok, karatan dan
●
berfungsi dengan baik)
13 Drag Drum No leak (tidak bocor) ●
14 Boom foot Good function and no noise (berfungsi dengan baik dan tidak
bisisng ● ●
15 Hoist drum Work smoothly (bekerja dengan baik) ● ●

INSPECTION STATUS
PASSED

HOLD

REJECTED

SPECIAL NOTE FROM CLIENT:

INSPECTION BY APPROVED BY

Name and Signature Name and Signature

BG-06221IDa2.xlsx
 Security Level 2
BG-06221ID

Appendix (2)-
Form no: Form-I-049
Inspection Date :
DRAG-LINE / CLAMSHELL Location of Inspection :

INSPECTION STANDARD Company/Subcontractor :

Validty of inspection :
(PER.05/MEN/1985 PESAWAT ANGKAT DAN ANGKUT) Type of inspection : Monthly for High Risk/ every 3 Months
This form must be completed by the operator and company user before entering the equipment to site project and to be operated. All equipment conditon must meet to the safety regulation, government regulation and IKPT
SHES Plan.
Stiker Number

Stiker Number

Stiker Number

BG-06221IDa2.xlsx
 Security Level 2
BG-06221ID

Appendix (2)-
Form no: Form-I-049 A

DRAG-LINE / CLAMSHELL
Inspection Date :
Location of Inspection :

DAILY CHECK LIST Company/Subcontractor :

Validty of inspection :
(PER.05/MEN/1985 PESAWAT ANGKAT DAN ANGKUT) ID NO: DL/CS - …….

This form must be completed by the operator and leader user before the equipment to be operated. All equipment conditon must meet to the safety regulation, government regulation and IKPT SHES Plan.
Period: / / to / /
No INSPECTION ITEM STANDARDS Senin Selasa Rabu kamis Jumat Sabtu Minggu REASON FOR NOT COMPLY
1 Main Engine (mesin utama) No abnormal noise, no Leak, easy for start and off, no
spark (Tidak berisik, bocor,mudah di hidup dan
matikan, tidak ada percikan api)
2 Battery ( Accu ) Have cover by isolator material ex. Rubber,hard plastic
(memiliki penutup dari material isolator ex. Karet,
plastik yg keras)
3 Battery cable connections Are tight (rapat)
(sambungan kabel accu)
4 Fuel tank cover Tight and lock (rapat dan terkunci)

5 Radiator No leak (tidak bocor)

6 Horn (klakson) Work properly (berfungsi dengan baik)
7 Fuel system ( sistem bahan bakar) No leak (tidak bocor)
8 Rear view mirrors (kaca spion) As manufacturing standard (sesuai dengan standar
pabrikan)
9 Windshied wipers Work properly (berfungsi dengan baik)
10 Stop lights (lampu stop) Work properly (berfungsi dengan baik)
11 Rotary Lamp Work properly (berfungsi dengan baik)
12 Reverse lamp and sign (lampu Work properly (berfungsi dengan baik)
mundur dan bel)
13 Break system (sistem pengereman) Work properly (berfungsi dengan baik)

14 Crawler No crack, recondition, bare (tidak

retak,rekondisi,gundul)
15 Dragline/clampshell No crack and work properly (tidak retak dan berfungsi
dengan baik)
16 Hoist chain No broken, rusty and crack of chain (tidak rusak, karat
utama ) dan retak)
17 Dump rope No damage and rusty (tidak rusak dan karatan)
18 Drag chain No broken and crack of chain (tidak rantai putus dan
19 Hoist rope No damage and rusty(tidak rusak dan karatan)
20 Drag Drum No leak (tidak bocor)
21 Boom foot Good function and no noise (berfungsi dengan baik dan
tidak bisisng
22 Hoist drum Work smoothly (bekerja dengan baik)
23 Fire extinguisher Available (ada)

24 First Aid Box Available (ada)

REMARKS

BG-06221IDa2.xlsx
 Security Level 2
BG-06221ID
Appendix (2)-
Form no: Form-I-051 56 /89

LORRY/COMMON TRUCK
Inspection Date :
Location of Inspection :

INSPECTION STANDARD
Company/Subcontractor :
Validty of inspection :
(SK.725/AJ.302/DRJD/2004;PP/187/1999 ) Type of inspection : Monthly for High Risk/ every 3 Months
This form must be completed by the operator and company user before entering the equipment to site project and to be operated. All equipment conditon must meet to the safety regulation, government regulation and IKPT
SHES Plan.
EQUIPMENT CARRY-IN CERTIFICATE
Type: Police No:
Machine/Engine No: Certificate (STNK) No:
Serial/Plate/Body No.: Certifcate Validity:
Manufacture /Year: Validity Vehicle test by Government (KIR):
Lifting manufacture / Year: Equip. Operation license (SILO/SIA) no.:
Capacity: Equip. Operation license (SILO/SIA) Validity:
Serial Lifting No: Opertor Name:
ID No: LR/CO - …….. Operator License (SIO) No. :
Operator license (SIO) Validity:
INSPECTION METHOD INSPECTION RESULT
No INSPECTION ITEM STANDARDS REASON FOR NOT COMPLY
VISUAL FUNCTION IKPT CLEINT
Common
1 Maintenance record For the pass year is available ●
2 Daily check list For the pass 3 months is available ●
Engine (mesin) No abnormal noise,no Leak, easy for start and off, no spark (Tidak
3 berisik, bocor,mudah di hidup dan matikan, tidak ada percikan api) ● ●

4 Engine starting Easy for start and stop (mudah untuk dinyalakan dan matikan) ●
Battery ( Accu ) Have cover by isolator material ex. Rubber,hard plastic( memiliki
5 ●
peutup dari material isolator ex. Karet, plastik yg keras)
Not leak, the condition is still safe in accordance with the
manufacture, the front wheels are not retread (Tidak bocor,
6 Wheel tire (ban\roda) kondisi masih aman sesuai dengan manufacture, roda depan ●
bukan vulkanisir)

Fuel cap (Tutup Tanki Bahan Bakar) Available, safe, and according to vehicle standards (Tersedia, ●
7 aman, dan sesuai standar kendaraan)

8 Fuel oil (Tanki Bahan Bakar) no leak (Tidak bocor) ●

Battery\Accu(Penutup aki\battery) All surfaces that may arise sparks must be closed (Semua ●
9 permukaan aki yang mungkin timbul percikan api harus
ditutup)
dengan bahan isolator dan tidak mudah terbakar.
10 Rear view mirror(Spion) clear and clean (Jelas dan bersih). ●

11 Horn (Klakson) Good function (Berfungsi dengan baik) ●

Engine (Mesin) Works safely and has no leaks (Bekerja dengan aman dan tidak ada ●
12 kebocoran)
Brake (Rem) Works safely and has no leaks (Berfungsi dengan baik dan tidak ●
13
ada bocor)
14 Hand brake (Rem Tangan) Good function (Berfungsi dengan baik) ●

Head,signal lamp (Lampu besar, rem, Good function (Berfungsi dengan baik) ●
15 sein)
16 Wiper Good function (Berfungsi dengan baik) ●

Electrical switch off mesin Available and good function (Tersedia dan berfungsi dengan baik) ●
17
Reverse alarm (Alarm Mundur) and Available and good function (Tersedia dan berfungsi dengan baik) ● ●
18
lamp
Rotary lamp Available and good function (Tersedia dan berfungsi dengan baik) ● ●
19

20 FE (Alat pemadam api ringan) available and minimu 2 botle (Tersedia minimal 2 tabung ) ●

21 Safety conne / segitiga pengaman available and minimu 2 ea (Tersedia dan minimal 2 ea) ●

22 First Aid Box available (Tersedia) ●

Special Requirement

1 2 or 4 or more wheel drive Good function (Berfungsi dengan baik) ●

2 Hazard sign (Simbol rambu B3) Available and readable (Tersedia dan terbaca) ●

3 Ladder (Tangga) Easy to access and not damaged (Mudah diakses dan tidak rusak) ●

4 Tankage (Tangki)/ Box (full or open no leak /no damage (Tidak ada kebocoran/tidak rusak) ●
top)
5 Tank indicator (Indikator pada tanki Good function (Berfungsi dengan baik) ●
(Temperatur/TI & Tekanan/PG))
6 Cabin Indicator (Indikator pada kabin) Good function (Berfungsi dengan baik) ●

7 Flame arrestor available and installed (Tersedia dan terpasang) ●

8 ISO tank certificate (Sertifikasi ISO Sertifikasi masih berlaku dan kondisi baik. ●
Tank)
Safety helmet min req. 2 unit. ● ●
Safety glass / goggles min req. 2 unit ● ●
Face shield min req. 2 unit ● ●
9 Special PPE half mask / full face mask chemical min req. 2 unit ● ●
Chemical suit min req. 2 unit ● ●
Chemical gloves req. 2 unit. ● ●
Safety shoes or safety boot min req. 2 unit ● ●

INSPECTION STATUS
PASSED

HOLD

REJECTED

BG-06221IDa2.xlsx
 Security Level 2
BG-06221ID
Appendix (2)-
Form no: Form-I-051 57 /89

LORRY/COMMON TRUCK
Inspection Date :
Location of Inspection :

INSPECTION STANDARD
Company/Subcontractor :
Validty of inspection :
(SK.725/AJ.302/DRJD/2004;PP/187/1999 ) Type of inspection : Monthly for High Risk/ every 3 Months
This form must be completed by the operator and company user before entering the equipment to site project and to be operated. All equipment conditon must meet to the safety regulation, government regulation and IKPT
SHES Plan.
SPECIAL NOTE FROM CLIENT :

INSPECTION BY APPROVED BY

Name and Signature Name and Signature

Stiker Number

Stiker Number

Stiker Number

BG-06221IDa2.xlsx
 Security Level 2
BG-06221ID
Appendix (2)-
Form no: Form-I-051A 58 /89

LORRY/COMMON TRUCK
Inspection Date :
Location of Inspection :

DAILY CHECK LIST

Company/Subcontractor :
Validty of inspection :
(SK.725/AJ.302/DRJD/2004;PP/187/1999 ) ID NO: LR/CO - …….
This form must be completed by the operator and leader user before the equipment to be operated. All equipment conditon must meet to the safety regulation, government regulation and IKPT SHES Plan.
Period / / to /
No INSPECTION ITEM STANDARDS : / REASON FOR NOT COMPLY
Senin Selasa Rabu kamis Jumat Sabtu Minggu
Engine (mesin) No abnormal noise,no Leak, easy for start and off, no spark
1 (Tidak berisik, bocor,mudah di hidup dan matikan, tidak ada
percikan api)
Battery ( Accu ) Have cover by isolator material ex. Rubber,hard plastic
2 (memiliki peutup dari material isolator ex. Karet, plastik yg
keras)
Battery cable connections (sambungan Are tight (rapat)
3
kabel accu)
Not leak, the condition is still safe in accordance with the
manufacture, the front wheels are not retread (Tidak bocor,
4 Wheel tire (ban\roda)
kondisi masih aman sesuai dengan manufacture, roda
depan bukan vulkanisir)
Fuel cap (Tutup Tanki Bahan Bakar) Available, safe, and according to vehicle standards (Tersedia,
5 aman, dan sesuai standar kendaraan)

6 Fuel oil (Tanki Bahan Bakar) no leak (Tidak bocor)

7 Rear view mirror(Spion) clear and clean (Jelas dan bersih).

8 Horn (Klakson) Good function (Berfungsi dengan baik)

Engine (Mesin) Works safely and has no leaks (Bekerja dengan aman
9 dan tidak ada kebocoran)
Brake (Rem) Works safely and has no leaks (Berfungsi dengan baik dan
10
tidak ada bocor)
11 Hand brake (Rem Tangan) Good function (Berfungsi dengan baik)

Head,signal lamp (Lampu besar, rem, Good function (Berfungsi dengan baik)
12 sein)
13 Wiper Good function (Berfungsi dengan baik)

Reverse alarm (Alarm Mundur) and Available and good function (Tersedia dan berfungsi dengan
14
lamp baik)
Rotary lamp Available and good function (Tersedia dan berfungsi dengan
15
baik)
Tankage (Tangki)/ Box (full or no leak /no damage (Tidak ada kebocoran/tidak rusak)
16 open top)
Tank indicator (Indikator pada tanki Good function (Berfungsi dengan baik)
17 (Temperatur/TI & Tekanan/PG))
18 Flame arrestor available and installed (Tersedia dan terpasang)
Safety helmet min req. 2 unit.
Safety glass / goggles min req. 2 unit
Face shield min req. 2 unit
19 Special PPE half mask / full face mask chemical min req. 2 unit
Chemical suit min req. 2 unit
Chemical gloves req. 2 unit.
Safety shoes or safety boot min req. 2 unit
20 FE (Alat pemadam api ringan) available and minimu 2 botle (Tersedia minimal 2 tabung )

21 Safety conne / segitiga pengaman available and minimu 2 ea (Tersedia dan minimal 2 ea)

22 First Aid Box available (Tersedia)

OPERATOR
SIGNED BY
LEADER
REMARKS

BG-06221IDa2.xlsx
 Security Level 2
BG-06221ID
Appendix (2)-
Form no: Form-I-052
59 /89

Inspection Date :
DUMP TRUCK/ TRUCK Location of Inspection :
Company/Subcontractor :

INSPECTION STANDARD Validty of inspection :

Type of inspection : Monthly / High Risk every 3 Months
(PP/No.50/2012 & OSHA 29 CFR 1910)
This form must be completed by the operator and company user before entering the equipment to site project and to be operated. All equipment conditon must meet to the safety regulation,
government regulation and IKPT SHES Plan.
EQUIPMENT CARRY-IN CERTIFICATE
Type: Police No:

Machine/Engine No: Certificate (STNK) No:

Serial/Plate/Body No.: Certifcate Validity:

Manufacture / Year: Validity Vehicle test by Government (KIR):

Lifting manufacture / Year: Equip. Operation license (SILO/SIA) no.:

Capacity: Equip. Operation license (SILO/SIA) Validity:

Serial Lifting No: Opertor Name:

ID No: DT/TR - ………… Operator License (SIO) No. :

Operator license (SIO) Validity:

INSPECTION METHOD INSPECTION RESULT
No INSPECTION ITEM STANDARDS VISUAL FUNCTION IKPT Client REASON FOR NOT COMPLY
Common

1 Maintenance record For the pass year is available ●

2 Daily check list For the pass 3 months is available ●
3 Engine (mesin) No abnormal noise,no Leak, easy for start and off, no spark
(Tidak berisik, bocor,mudah di hidup dan matikan, tidak ada ● ●
4 Engine starting Easy for start and stop (mudah untuk dinyalakan dan matikan) ●
5 Wheel tire (ban) Not inflated, as manufacturing standard (Tidak bocor, kondisi
masih
●
6 Fuel cap (tutup bahan bakar) Tight,as manufacturing standard (rapat,sesuai standar
pabrikan) ●
7 Fuel tank (tangki bahan bakar) Not leak (tidak bocor)
●
8 Accu cover (tutup aki) Cover all surface with isolator material ex.rubber (menutup
seluruh permukaan dengan material isolator ex.karet) ●
9 Reaview mirror (Spion) Clear (Jelas ) ●
10 Horn (Klakson) Good Function (berfungsi dengan baik) ●
11 Brake (Rem) Good Function (berfungsi dengan baik) ●
12 Hand brake (Rem Tangan) Good Function (berfungsi dengan baik) ● `

13 Head,brake,signal light Good Function (berfungsi dengan baik) ●

(Lampu besar, rem, sein)
14 Reverse lamp and sign (lampu Good Function (berfungsi dengan baik) ● ●
mundur dan bel)
15 Cabin indicator (Indikator Good Function (berfungsi dengan baik) ● ●
pada kabin)
16 Wiper Good Function (berfungsi dengan baik) ●
17 Fire extinguisher (Alat Available and minimum 1 bottle (ada dan minimal 1 tabung ) ●
pemadam api ringan)
18 Safety conne / segitiga Available and minimum 2 ea (tersedia dan minimal 2 ea) ●
19 First aid Box Available (tersedia ) ●
Special Requirement

1 2 or 4 or more wheel drive Good Function (berfungsi dengan baik) ●

2 Hazard sign As manufacturing standard (sesuai dengan standar pabrikan) ●

3 Ladder (Tangga) Accessible,not damage (Mudah diakses dan tidak rusak) ●

4 Flame arrestor Available and installed (tersedia dan terpasang) ●

INSPECTION STATUS : PASS REJECT HOLD

SPECIAL NOTE FROM CLIENT :

INSPECTION BY APPROVED BY

Name and Signature Name and Signature

Stiker Number

Stiker Number

Stiker Number

BG-06221IDa2.xlsx
 Security Level 2
BG-06221ID
Appendix (2)-
60 /89
Form no: Form-I-052A

DUMP TRUCK/ TRUCK

Inspection Date :
Location of Inspection :

DAILY CHECK LIST Company/Subcontractor :

Validty of inspection :

(PP/No.50/2012 & OSHA 29 CFR 1910) ID NO: DT/TR - …….

This form must be completed by the operator and leader user before the equipment to be operated. All equipment conditon must meet to the safety regulation, government regulation and IKPT SHES Plan.
Period: / / to / /
No INSPECTION ITEM STANDARDS Senin Selasa Rabu kamis Jumat Sabtu Minggu REASON FOR NOT COMPLY

1 Engine (mesin) No abnormal noise,no Leak, easy for start and off, no spark
(Tidak berisik, bocor,mudah di hidup dan matikan, tidak
ada percikan api)
2 Wheel tire (ban) Not inflated, as manufacturing standard (Tidak bocor, kondisi
masih
3 Fuel cap (tutup bahan bakar) Tight,as manufacturing standard (rapat,sesuai standar
pabrikan)
4 Fuel tank (tangki bahan bakar) Not leak (tidak bocor)

5 Accu cover (tutup aki) Cover all surface with isolator material ex.rubber (menutup
seluruh permukaan dengan material isolator ex.karet)

6 Battery cable connections Are tight (rapat)

(sambungan kabel accu)
7 Reaview mirror (Spion) Clear (Jelas )
8 Horn (Klakson) Good Function (berfungsi dengan baik)
9 Brake (Rem) Good Function (berfungsi dengan baik)
10 Hand brake (Rem Tangan) Good Function (berfungsi dengan baik) `
11 Head,brake,signal light Good Function (berfungsi dengan baik)
(Lampu besar, rem, sein)
12 Reverse lamp and sign (lampu Good Function (berfungsi dengan baik)
mundur dan bel)
13 Wiper Good Function (berfungsi dengan baik)
14 Hazard sign As manufacturing standard (sesuai dengan standar pabrikan)

15 Flame arrestor Available and installed (tersedia dan terpasang)

16 Fire extinguisher (Alat Available and minimum 1 bottle (ada dan minimal 1 tabung )
pemadam api ringan)
17 Safety conne / segitiga Available and minimum 2 ea (tersedia dan minimal 2 ea)
18 First aid Box Available (tersedia )

REMARKS

BG-06221IDa2.xlsx
 Security Level 2
BG-06221ID
Appendix (2)-

Form No. Form-I-053

61 /89

Inspection Date :
Location of Inspection :
Company/Subcontractor :
AMBULANCE INSPECTION STANDARD Validty of inspection :
Type of inspection : Monthly for High Risk/ every 3 Months
This form must be completed by the operator and company user before entering the equipment to site project and to be operated. All equipment conditon must meet to the safety regulation,
government regulation and IKPT SHES Plan.
EQUIPMENT CARRY-IN CERTIFICATE
Type: Police No:
Machine/Engine No: Certificate (STNK) No:
Serial/Plate/Body No.: Certifcate Validity:
Manufacture / Year: Validity Vehicle test by Government (KIR):
Lifting manufacture / Year: Equip. Operation license (SILO/SIA) no.:
Capacity: Equip. Operation license (SILO/SIA) Validity:
Serial Lifting No: Opertor Name:
ID No: AB- ………… Operator License (SIO) No. :
Operator license (SIO) Validity:
INSPECTION INSPECTION
No. INSPECTION ITEM STANDARDS VISUAL FUNCTION IKPT CLIENT REASON FOR NOT COMPLY
Common
1 Maintenance record For the pass year is available ●
2 Daily check list For the pass 3 months is available ●
Not inflated, as manufacturing standard
3 Wheel tire (ban) (Tidak bocor, kondisi masih aman sesuai ●
dengan pabrikan)
Fuel cap (tutup bahan bakar) Tight,as manufacturing standard
4 (rapat,sesuai standar pabrikan) ● ●
Fuel tank (tangki bahan Not leak (tidak bocor)
5 bakar) ●
cover all surface with isolator material
6 Accu cover (tutup aki) ex.rubber (menutup seluruh ●

7 Reaview mirror (Spion) Clear (Jelas ) ●

8 Horn (Klakson) work (Berfungsi dengan baik) ● ●
Engine (Mesin) work,No leak,noise (berfungsi,tidak bocor,
9 ● ●
10 Brake (Rem) Good function (Berfungsi dengan baik) ●
Hand brake (Rem Tangan) Good function (Berfungsi dengan baik)
11 ● ●
Head,brake,signal light Good function (Berfungsi dengan baik)
12
(Lampu besar, rem, sein) ● ●
Reverse Lamp and sign Good function (Berfungsi dengan baik)
13
(lampu mundur dan bel) ● ●
Cabin indicator (Indikator Good function (Berfungsi dengan baik)
14
pada kabin) ● ●
15 Wiper Good function (Berfungsi dengan baik) ● ●
16 Fire Exthinguesher Good function (Berfungsi dengan baik) ● ●
Special Requirement
1 2 or 4 or more wheel drive Good function (Berfungsi dengan baik) ● ●
2 Rotary Lamp Good function (Berfungsi dengan baik) ● ●
3 Sirens sound complete with Good function (Berfungsi dengan baik)
Multi Mic ● ●
4 Seating the nurse comes with Available
Box equipment ●
5 The runway is equipped with Good function (Berfungsi dengan baik)
a litter Scoop Stretcher ● ●
6 Lamp Spotlight Good function (Berfungsi dengan baik) ● ●
7 2 pieces lamp operating Good function (Berfungsi dengan baik) ● ●
8 Logos and Writing Standard Available
of 3M ●
9 Glass film 60-80% Available ●
10 Acrylic Finishing equipment Available
cabinets ●
11 Gantungan Infuse model Good function (Berfungsi dengan baik)
geser ●
12 Central Oxygen System
BSS, CK – 201 ● ●
13 2 Oxygen Tube Good function (Berfungsi dengan baik) ● ●
14 2 Standard Regulator Good function (Berfungsi dengan baik) ● ●
15 1 set the hose system with Good function (Berfungsi dengan baik)
high pressure Oxygen press ● ●
16 1 set of Oxygen Regulator Good function (Berfungsi dengan baik)
with On/Off tap ● ●
17 1 set Flowmeter and Good function (Berfungsi dengan baik)
Humidifier ● ●
18 1 piece of Oxygen Masks Available ● ●

BG-06221IDa2.xlsx
 Security Level 2
BG-06221ID
Appendix (2)-
62 /89
Form No. Form-I-053
Inspection Date :
Location of Inspection :
Company/Subcontractor :
AMBULANCE INSPECTION STANDARD Validty of inspection :
Type of inspection : Monthly for High Risk/ every 3 Months
This form must be completed by the operator and company user before entering the equipment to site project and to be operated. All equipment conditon must meet to the safety regulation,
government regulation and IKPT SHES Plan.
19 1 piece of a Nasal Cannula Available ● ●

INSPECTION STATUS

PASSED

HOLD

REJECTED

SPECIAL NOTE FROM CLIENT:

INSPECTION BY APPROVED BY

Name and Signature Name and Signature

Stiker Number

Stiker Number

Stiker Number

BG-06221IDa2.xlsx
 Security Level 2
BG-06221ID
Appendix (2)-

Form No. Form-I-053A

63 /89

Inspection Date :
Location of Inspection :
Company/Subcontractor :
AMBULANCE DAILY CHECK LIST Validty of inspection :
ID NO: AB - …….
This form must be completed by the operator and leader user before the equipment to be operated. All equipment conditon must meet to the safety regulation, government regulation and IKPT
SHES Plan.
Period / / to /
No. INSPECTION ITEM STANDARDS : / REASON FOR NOT COMPLY
Senin Selasa Rabu kamis Jumat Sabtu Minggu
Not inflated, as manufacturing standard
1 Wheel tire (ban) (Tidak bocor, kondisi masih aman
sesuai dengan pabrikan)
Fuel cap (tutup bahan bakar) Tight,as manufacturing standard
2 (rapat,sesuai standar pabrikan)
Fuel tank (tangki Not leak (tidak bocor)
3 bahan bakar)
Cover all surface with isolator material
4 Accu cover (tutup aki) ex.rubber (menutup seluruh
permukaan dengan material isolator
ex.karet)
Battery cable Are tight (rapat)
5
connections (sambungan
kabel accu)
6 Reaview mirror (Spion) Clear (Jelas )

7 Horn (Klakson) work (Berfungsi dengan baik)

Engine (Mesin) work,No leak,noise (berfungsi,tidak bocor,
8

9 Brake (Rem) Good function (Berfungsi dengan baik)

Hand brake (Rem Tangan) Good function (Berfungsi dengan baik)
10
Head,brake,signal light Good function (Berfungsi dengan baik)
11
(Lampu besar, rem, sein)
Reverse Lamp and sign Good function (Berfungsi dengan baik)
12
(lampu mundur dan bel)
13 Wiper Good function (Berfungsi dengan baik)
14 Rotary Lamp Good function (Berfungsi dengan baik)
Sirens sound complete Good function (Berfungsi dengan baik)
15 with Multi Mic
16 Lamp Spotlight Good function (Berfungsi dengan baik)

17 2 pieces lamp operating Good function (Berfungsi dengan baik)

18 2 Oxygen Tube Good function (Berfungsi dengan baik)

19 2 Standard Regulator Good function (Berfungsi dengan baik)

1 set the hose system with Good function (Berfungsi dengan baik)
20
high pressure Oxygen press
1 set of Oxygen Regulator Good function (Berfungsi dengan baik)
21
with On/Off tap
1 set Flowmeter and Good function (Berfungsi dengan baik)
22
Humidifier
23 Fire Exthinguesher Good function (Berfungsi dengan baik)

OPERATOR
SIGNED BY
LEADER
REMARKS

BG-06221IDa2.xlsx
 Security Level 2
BG-06221ID
Appendix (2)-
64 /89
Form No.: Form-I-054
Inspection Date :
COMMON VEHICLE Location of Inspection :
Company/Subcontractor :
INSPECTION STANDARD Validty of inspection :
Type of inspection : Monthly for High Risk/ every 3 Months
(PP/No.50/2012 & OSHA 29 CFR 1910)
This form must be completed by the operator and company user before entering the equipment to site project and to be operated. All equipment conditon must meet to the safety regulation, government
regulation and IKPT SHES Plan.
EQUIPMENT CARRY-IN CERTIFICATE
Type: Police No:

Machine/Engine No: Certificate (STNK) No:

Serial/Plate/Body No.: Certifcate Validity:

Manufacture / Year: Validity Vehicle test by Government (KIR):

Lifting manufacture / Year: Equip. Operation license (SILO/SIA) no.:

Capacity: Equip. Operation license (SILO/SIA) Validity:

Serial Lifting No: Opertor Name:

ID No: VH - ………… Operator License (SIO) No. :

Operator license (SIO) Validity:
INSPECTION METHOD INSPECTION RESULT
No INSPECTION ITEM STANDARDS REASON FOR NOT COMPLY
VISUAL FUNCTION IKPT CLIENT
Common

1 Maintenance record For the pass year is available ●

2 Daily check list For the pass 3 months is available ●
3 Wheel tire (ban) Not inflated, as manufacturing standard (Tidak bocor, kondisi ●
masih
4 Fuel cap (tutup bahan Tight,as manufacturing standard (rapat,sesuai standar ●
bakar) pabrikan)
5 Fuel tank (tangki bahan Not leak (tidak bocor) ●
bakar)
6 Accu cover (tutup aki) cover all surface with isolator material ex.rubber (menutup ●
seluruh permukaan dengan material isolator ex.karet)
7 Reaview mirror (Spion) Clear (Jelas ) ●
8 Horn (Klakson) Good function (Berfungsi dengan baik) ●
9 Engine (Mesin) Function, No leak, no noise (berfungsi,tidak bocor, tidak ●
bising)
10 Brake (Rem) Good function (Berfungsi dengan baik) ●
11 Hand brake (Rem Tangan) Good function (Berfungsi dengan baik) ● `

12 Head,brake,signal light Good function (Berfungsi dengan baik) ● ●

(Lampu besar, rem, sein)
13 Reverse Light and sign Good function (Berfungsi dengan baik) ● ●
(lampu mundur dan bel)
14 Cabin indicator (Indikator Good function (Berfungsi dengan baik) ● ●
pada kabin)
15 Wiper Good function (Berfungsi dengan baik) ●
16 Reverse lamp and sign Good function (Berfungsi dengan baik) ●
(lampu mundur dan
bel)
Special Requirement

1 2 or 4 or more wheel Drive Good function (Berfungsi dengan baik) ● ●

2 Fire extinguisher (Alat Available and minimum 1 botte (tersedia dan minimal 1 ●
pemadam api ringan) tabung)
3 Safety conne / segitiga Available and minimum 2 ea (tersedia dan minimal 2 ea) ●
4 First aid Box available (tersedia ) ●

INSPECTION PASS REJECT HOLD

SPECIAL NOTE FROM CLIENT :

INSPECTION BY APPROVED BY

Name and Signature Name and Signature

Stiker Number

Stiker Number

Stiker Number

BG-06221IDa2.xlsx
 Security Level 2
BG-06221ID
Appendix (2)-
65 /89
Form No. Form-I-054A
Inspection Date :
COMMON VEHICLE Location of Inspection :
Company/Subcontractor :
DAILY CHECK LIST Validty of inspection :
ID NO: VH - …….
(PP/No.50/2012 & OSHA 29 CFR 1910)
This form must be completed by the operator and leader user before the equipment to be operated. All equipment conditon must meet to the safety regulation, government regulation and IKPT SHES Plan.
Period: / / to / /
No INSPECTION ITEM STANDARDS Senin Selasa Rabu kamis Jumat Sabtu Minggu REASON FOR NOT COMPLY
1 Wheel tire (ban) Not inflated, as manufacturing standard (Tidak bocor,
kondisi masih aman sesuai dengan pabrikan)
2 Fuel cap (tutup bahan bakar) Tight,as manufacturing standard (rapat,sesuai standar
pabrikan)
3 Accu cover (tutup aki) cover all surface with isolator material ex.rubber (menutup
seluruh permukaan dengan material isolator ex.karet)
4 Battery cable connections Are tight (rapat)
(sambungan kabel accu)
5 Reaview mirror (Spion) Clear (Jelas )
6 Horn (Klakson) Good function (Berfungsi dengan baik)

7 Engine (Mesin) Function, No leak, no noise (berfungsi,tidak bocor, tidak

bising)
8 Brake (Rem) Good function (Berfungsi dengan baik)

9 Hand brake (Rem Tangan) Good function (Berfungsi dengan baik) `

10 Head,brake,signal light Good function (Berfungsi dengan baik)

(Lampu besar, rem, sein)
11 Reverse Light and sign Good function (Berfungsi dengan baik)
(lampu mundur dan bel)
12 Cabin indicator (Indikator Good function (Berfungsi dengan baik)
pada kabin)
13 Wiper Good function (Berfungsi dengan baik)

14 Reverse lamp and sign Good function (Berfungsi dengan baik)

(lampu mundur dan bel)
15 Fire extinguisher (Alat Available and minimum 1 botte (tersedia dan minimal 1
pemadam api ringan) tabung)
16 First aid Box available (tersedia )

OPERATOR
SIGNED BY
LEADER
REMARKS

BG-06221IDa2.xlsx
 Security Level 2
BG-06221ID

Appendix (2)-
Form no: Form-I-055

TRAILER TRUCK
Inspection Date :
Location of Inspection :

INSPECTION STANDARD
Company/Subcontractor :
Validty of inspection :
(SK.725/AJ.302/DRJD/2004;PP/187/1999 ) Type of inspection : Monthly for High Risk/ every 3 Months
This form must be completed by the operator and company user before entering the equipment to site project and to be operated. All equipment conditon must meet to the safety regulation, government regulation and IKPT
SHES Plan.
EQUIPMENT CARRY-IN CERTIFICATE
Type: Police No:
Machine/Engine No: Certificate (STNK) No:
Serial/Plate/Body No.: Certifcate Validity:
Manufacture / Year : Validity Vehicle test by Government (KIR):
Lifting manufacture / Year : Equip. Operation license (SILO/SIA) no.:
Capacity: Equip. Operation license (SILO/SIA) Validity:
Serial Lifting No: Opertor Name:
ID No: TT - …….. Operator License (SIO) No. :
Operator license (SIO) Validity:
INSPECTION METHOD INSPECTION RESULT
No INSPECTION ITEM STANDARDS REASON FOR NOT COMPLY
VISUAL FUNCTION IKPT CLIENT
Common
1 Maintenance record For the pass year is available ●
2 Daily check list For the pass 3 months is available ●
Wheel tire (ban\roda) at Prime Mover Not leak, the condition is still safe in accordance with the
manufacture, the front wheels are not retread (Tidak bocor,
3 ●
kondisi masih aman sesuai dengan manufacture, roda depan
bukan vulkanisir)
Fuel cap (Tutup Tanki Bahan Bakar) Available, safe, and according to vehicle standards (Tersedia, ●
4 aman, dan sesuai standar kendaraan)

5 Fuel oil (Tanki Bahan Bakar) no leak (Tidak bocor) ●

Battery\Accu(Penutup aki\battery) All surfaces that may arise sparks must be closed (Semua ●
6 permukaan aki yang mungkin timbul percikan api harus
ditutup)
dengan bahan isolator dan tidak mudah terbakar.
7 Reaview mirror(Spion) clear and clean (Jelas dan bersih). ●

8 Horn (Klakson) Good function (Berfungsi dengan baik) ●

Engine (Mesin) Works safely and has no leaks (Bekerja dengan aman dan tidak ● ●
9
ada kebocoran)

10 Hand brake (Rem Tangan) Good function (Berfungsi dengan baik) ●

Transmission Good function and no problems when passing gear (Berfungsi ● ●

11 dengan baik dan tidak ada masalah saat melewati gigi)

Head,signal lamp (Lampu besar, rem, Good function (Berfungsi dengan baik) ●
12 sein)
13 Wiper Good function (Berfungsi dengan baik) ●

Electrical switch off mesin Available and good function (Tersedia dan berfungsi dengan ●
14
baik)
Reverse alarm (Alarm Mundur) and Available and good function (Tersedia dan berfungsi dengan ● ●
15
lamp baik)
Rotary lamp Available and good function (Tersedia dan berfungsi dengan ● ●
16
baik)
Cabin Indicator (Indikator pada kabin) Good function (Berfungsi dengan baik) ●
17

FE (Alat pemadam api ringan) available and minimum 1 botle (Tersedia minimal 1 tabung ) ●
18

19 Safety conne / segitiga pengaman available and minimu 2 ea (Tersedia dan minimal 2 ea) ●

20 Flame arrestor available and installed (Tersedia dan terpasang) ●

21 1st Aid box available and installed (Tersedia dan terpasang) ●

Special Requirement

1 2 or 4 or more wheel drive do not disturb other vehicles (tidak mengganggu kendaraan lain ●

2 Exhaust do not disturb other vehicles (tidak mengganggu kendaraan lain ●

3 Fifth wheel Solid and in good condition (solid dan dalam kondisi baik) ●

4 Electrical wiring and plugs Good condition (kondisi baik) ● ●

5 Air lines Good condition and no leak (kondisi baik dan tidak Bocor) ● ●

6 Spring bar hinges and safety clips Available and good function (ada dan berfungsi dengan baik) ● ●

7 Receiver locking pin Good condition (kondisi baik) ● ●

8 Trailer nose jack Works properly (bekerja dengan baik) ● ●

9 Brake (Rem) of trailer Works properly (bekerja dengan baik) ● ●

10 Brake and signal lamp (rem dan sein) Good function (Berfungsi dengan baik) ● ●
trailer
11 Reverse alarm (Alarm Mundur) and Available and good function (Tersedia dan berfungsi dengan ● ●
lamp for Trailer baik)
12 Front barrier (pelindung depan) available and installed (Tersedia dan terpasang) ●

Not leak, the condition is still safe in accordance with the

manufacture (Tidak bocor, kondisi masih aman sesuai dengan
13 Wheel tire (ban\roda) at trailler ●
manufacture)

BG-06221IDa2.xlsx
 Security Level 2
BG-06221ID

Appendix (2)-
Form no: Form-I-055

TRAILER TRUCK
Inspection Date :
Location of Inspection :

INSPECTION STANDARD
Company/Subcontractor :
Validty of inspection :
(SK.725/AJ.302/DRJD/2004;PP/187/1999 ) Type of inspection : Monthly for High Risk/ every 3 Months
This form must be completed by the operator and company user before entering the equipment to site project and to be operated. All equipment conditon must meet to the safety regulation, government regulation and IKPT
SHES Plan.
INSPECTION STATUS
PASSED

HOLD

REJECTED

SPECIAL NOTE FROM CLIENT :

INSPECTION BY APPROVED BY

Name and Signature Name and Signature

Stiker Number

Stiker Number

Stiker Number

BG-06221IDa2.xlsx
 Security Level 2
BG-06221ID

Appendix (2)-
Form no: Form-I-055A

TRAILER TRUCK
Inspection Date :
Location of Inspection :

DAILY CHECK LIST

Company/Subcontractor :
Validty of inspection :
(SK.725/AJ.302/DRJD/2004;PP/187/1999 ) ID NO: TT - …….
This form must be completed by the operator and leader user before the equipment to be operated. All equipment conditon must meet to the safety regulation, government regulation and IKPT SHES Plan.
Period: / / to / /
No INSPECTION ITEM STANDARDS REASON FOR NOT COMPLY
Senin Selasa Rabu kamis Jumat Sabtu Minggu
Wheel tire (ban\roda) Not leak, the condition is still safe in accordance with the
manufacture, the front wheels are not retread (Tidak bocor,
1
kondisi masih aman sesuai dengan manufacture, roda depan
bukan vulkanisir)
Fuel cap (Tutup Tanki Bahan Bakar) Available, safe, and according to vehicle standards (Tersedia,
2 aman, dan sesuai standar kendaraan)
Battery\Accu(Penutup aki\battery) Have cover by isolator material ex. Rubber,hard plastic (memiliki
3 peutup dari material isolator ex. Karet, plastik yg keras)

Battery cable connections (sambungan Are tight (rapat)

4 kabel accu)
5 Reaview mirror(Spion) clear and clean (Jelas dan bersih).

6 Horn (Klakson) Good function (Berfungsi dengan baik)

Engine (Mesin) Works safely and has no leaks (Bekerja dengan aman dan tidak
7 ada kebocoran)
8 Hand brake (Rem Tangan) Good function (Berfungsi dengan baik)

Head,signal lamp (Lampu besar, rem, Good function (Berfungsi dengan baik)
9 sein)
10 Wiper Good function (Berfungsi dengan baik)

Reverse alarm (Alarm Mundur) and Available and good function (Tersedia dan berfungsi dengan
11
lamp baik)
Rotary lamp Available and good function (Tersedia dan berfungsi dengan
12 baik)
13 Electrical wiring and plugs Good condition (kondisi baik)
Air lines Good condition and no leak (kondisi baik dan tidak Bocor)
14
Spring bar hinges and safety clips Available and good function (ada dan berfungsi dengan baik)
15

16 Receiver locking pin Good condition (kondisi baik)

17 Trailer nose jack Works properly (bekerja dengan baik)

18 Brake (Rem) of trailer Works properly (bekerja dengan baik)

Brake and signal lamp (rem dan sein) Good function (Berfungsi dengan baik)
19 trailer
Reverse alarm (Alarm Mundur) and Available and good function (Tersedia dan berfungsi dengan
20
lamp for Trailer baik)
Not leak, the condition is still safe in accordance with the
manufacture, the front wheels are not retread (Tidak bocor,
21 Wheel tire (ban\roda) kondisi masih aman sesuai dengan manufacture, roda depan
bukan vulkanisir)

FE (Alat pemadam api ringan) available and minimum 1 botle (Tersedia minimal 1 tabung )
22

23 Safety conne / segitiga pengaman available and minimu 2 ea (Tersedia dan minimal 2 ea)

24 1st Aid box available and installed (Tersedia dan terpasang)

OPERATOR
SIGNED BY
LEADER
REMARKS

BG-06221IDa2.xlsx
 Security Level 2
BG-06221ID

Appendix (2)-
Form-I-060
Inspection Date :
COMPRESSOR, GENSET, WATER JET Location of Inspection :
Company/Subcontractor :
INSPECTION STANDARD Validty of inspection :
Type of inspection : Monthly / High Risk every 3 Months
(PP/50/2012 & OSHA 1910.243)
Capacity : Seri No. / Year: ID NO:
Type of Equipment : Compressor Genset Water Jet
INSPECTION METHOD INSPECTION RESULT
No INSPECTION ITEM STANDARDS REASON FOR NOT COMPLY
VISUAL FUNCTION IKPT CLIENT
1 Maintenance record For the pass year is available ●
2 Daily check list For the pass 3 months is available ●
3 Engine No spark (mudah di start, tidak ada percikan) ●
4 Fuel tank No leak (tidak bocor) ●
5 Fuel tank cover As manufacturing standard (sesuai dengan standar ●
pabrikan)
6 Battery cover Cover all surface made from isolator material ex. ●
rubber (menutupi seluruh permukaan dengan
material isolator, cth. rubber)
7 Exhaust No leak (tidak bocor) ●
8 Flame arrestor As IKPT standard (sesuai dengan standard IKPT) ●
9 PSV Certified, work (bersertifikat, bekerja) ● ●
10 Compressor cylinder Not leak (tidak bocor) ● ●
11 Engine control switch Easy for start&stop (mudah untuk start&stop) ●
12 Connection plug Tight,not leak (rapat,tidak bocor) ●
13 Cover belt As manufacturing standard (sesuai dengan standar ●
pabrikan)
14 Motor housing Tight (rapat) ●
15 Pressure indicator Work (berfungsi) ●
16 Emergency stop Work,common visualization (berfungsi,terlihat ● ●
secara umum)
17 Valve Drain Not Leak (tidak bocor) ● ●
18 Panel indicator Work (berfungsi) ●
19 Lug Connection to breaker using lug (sambungan ke ●
breaker memakai lug)
Using proper cable as function
(outdoor/indoor),no direct connection cable to
20 Cable
cable (memakai kable yang sesuai fungsinya ●
luar/dalam),tidak boleh menyambung langsung
21 Grouding terminal Availlable,work (tersedia,berfungsi) ●
22 Hose Not abrasive,leak (tidak abrasif,bocor) ●
23 Hose connection As manufacturing standard (sesuai dengan standar ●
pabrikan)
24 Fire extinguisher Available (tersedia) ●

INSPECTION STATUS SPECIAL NOTE FROM CLIENT :

PASSED

HOLD INSPECTED BY APPROVED BY

REJECTED
Name & Signature Name & Signature

Compressor Genset Water Jet

PASSED

REJECT

HOLD
Stiker Number

Stiker Number

BG-06221IDa2.xlsx
 Security Level 2
BG-06221ID
Appendix (2)-
Form-I-060A
70 /89

Inspection Date :
COMPRESSOR, GENSET, WATER JET Location of Inspection :
Company/Subcontractor :
DAILY CHECK LIST Validt
ID NO:
(PP/50/2012 & OSHA 1910.243)
Capacity : Seri No. / Year:
Type of Equipment : Compressor Genset Water Jet
Period: / / to / /
No INSPECTION ITEM STANDARDS REASON FOR NOT COMPLY
Senin Selasa Rabu kamis Jumat Sabtu Minggu
1 Fuel tank No leak (tidak bocor)
2 Fuel tank cover As manufacturing standard (sesuai dengan standar
pabrikan)
3 Battery cover Cover all surface made from isolator material ex.
rubber (menutupi seluruh permukaan dengan
material isolator, cth. rubber)
4 Compressor cylinder Not leak (tidak bocor)
5 Engine control switch Easy for start&stop (mudah untuk start&stop)
6 Connection plug Tight,not leak (rapat,tidak bocor)
7 Cover belt As manufacturing standard (sesuai dengan standar
pabrikan)
8 Motor housing Tight (rapat)
9 Pressure indicator Work (berfungsi)
10 Emergency stop Work,common visualization (berfungsi,terlihat
secara umum)
11 Valve Drain Not Leak (tidak bocor)
12 Panel indicator Work (berfungsi)
13 Lug Connection to breaker using lug (sambungan ke
breaker memakai lug)
14 Using proper cable as function (outdoor/indoor),no
direct connection cable to cable (memakai kable
Cable
yang sesuai fungsinya luar/dalam),tidak boleh
menyambung langsung kabel ke kabel)
15 Grouding terminal Availlable,work (tersedia,berfungsi)
16 Hose Not abrasive, leak (tidak abrasif,bocor)
17 Hose connection As manufacturing standard (sesuai dengan standar
pabrikan)
18 Fire extinguisher Available (tersedia)

OPERATOR
SIGNED BY
LEADER
REMARKS

Compressor Genset Water Jet

BG-06221IDa2.xlsx
 Security Level 2
BG-06221ID
Appendix (2)-
Form no.: Form-I-061
71 /89

Inspection Date :
ELECTRICAL PANEL AND APPLIANCE Location of Inspection :
Company/Subcontractor :

INSPECTION STANDARD
Validty of inspection :
ID NO: Seri No. :
Type of inspection : Monthly for High Risk/ every 3 Months
(PP/50/2012 & OSHA 1910.243)
Capacity :
Type of Equipment : Electrical Panel Electrical
Appliance
INSPECTION METHOD INSPECTION RESULT
No INSPECTION ITEM STANDARDS REASON FOR NOT COMPLY
VISUAL FUNCTION OWNER CLIENT
1 ELCB Work, trip test (berfungsi, tes kegagalan) ● ●
2 Panel door Sealed,tight,min.IP.44 (terlindungi, rapat, min.IP.44) ●
3 Lock panel door Work (berfungsi) ● ●
4 Plug panel Min.IP.54,tight (min.IP54 , rapat) ●
5 Gland Min.IP.44 ●
6 Connection cable panel Connection cable to panel not direct but using cable lug ●
7 Panel body No hole, gas proof (tidak ada lubang,tahan gas) ●
8 Socket min.IP.44 ●
9 Cable Not scratch, well insulated , as manufacturing ●
instruction(Tidak terkelupas, terisolasi baik, sesuai dengan
10 Cable lug Tight (rapat) ●
11 Cable insulated As manufacturing guide (outdoor/indoor) ●
12 Junction box Gasproof, min.IP.44 (anti-gas min.IP.44) ●
13 Grounding cable Min.IP.44 ●
14 Receptable Max. hold 5 ohm, insulated ●
15 Connection cable Min.IP.44 ●
16 Grounding clamp Filamen conductor not damage, tight (filamen ●
konduktor tidak rusak, rapat)

INSPECTION STATUS SPECIAL NOTE FROM CLIENT :

PASSED
INSPECTED BY APPROVED BY
HOLD

REJECTED
Name & Signature Name & Signature

Gambar untuk tools ditampilkan dibelakang check list

Electrical Appliance Electrical Panel

PASSED

REJECT

HOLD

*Stiker Number

*Stiker Number

* Stiker Number

* For electrical assesoris not mandatory

BG-06221IDa2.xlsx
 Security Level 2
BG-06221ID
Appendix (2)-

Form-I-062
72 /89

Inspection Date :
WELDING MACHINE Location of Inspection
Company/Subcontract
INSPECTION STANDARD Validty of inspection :
Type of inspection : Monthly / High Risk every 3 Months
(PP/50/2012 & OSHA 1910.243)
Capacity : Seri No. / Year : ID NO : WM-…..
INSPECTION METHOD INSPECTION RESULT
No INSPECTION ITEM STANDARDS REASON FOR NOT COMPLY
VISUAL FUNCTION IKPT CLIENT
1 Maintenance record For the pass year is available ●
2 Daily check list For the pass 3 months is available ●
3 Engine No spark (mudah di start, tidak ada percikan) ●
4 Fuel tank No leak (tidak bocor) ●
5 Fuel tank cover As manufacturing standard (sesuai dengan standar
pabrikan) ●
6 Battery cover Cover all surface made from isolator material ex.
rubber (menutupi seluruh permukaan dengan ●
material isolator, cth. rubber)
7 Exhaust No leak (tidak bocor) ●
8 Flame arrestor As IKPT standard (sesuai dengan standard IKPT)
●
11 Engine control switch Easy for start&stop (mudah untuk start&stop) ● ●
12 Connection plug Tight,not leak (rapat,tidak bocor) ●
13 Cable internal As manufacturing standard (sesuai dengan standar
pabrikan) and as per volt & current (volt dan arus) ●
14 Motor housing Tight (rapat) ●
16 Emergency stop Work,common visualization (berfungsi,terlihat
secara umum) ● ●
18 Panel indicator Work (berfungsi) ● ●
19 Plug & Primary cable Connection is good and no burn (sambungan bagus
dan tidak terbakar) ●
20 Welding cable extention Female and Male connection are fully insulated
(sambungan laki dan perempuan terisolasi penuh)
and no damage (tidak ada rusak) ●

21 Grouding terminal Availlable,work (tersedia,berfungsi) ●

22 Current Electrical As per specification ● ●
23 Voltage Reduction Device (VRD) Good function (fungsinya baik) ● ●
24 Fire extinguisher Available (tersedia) ●

INSPECTION STATUS SPECIAL NOTE FROM CLIENT :

PASSED

INSPECTED BY APPROVED BY
HOLD

REJECTED
Name & Signature Name & Signature

Welding Machine
Stiker Number

Stiker Number

BG-06221IDa2.xlsx
 Security Level 2
BG-06221ID
Appendix (2)-

Form-I-062A
73 /89

Inspection Date
WELDING MACHINE Location of
Company/Subc
DAILY CHECK LIST Validty of
(PP/50/2012 & OSHA 1910.243)
Capacity : Seri No. / Year : ID NO : WM-…..
Period: / / to / /
No INSPECTION ITEM STANDARDS REASON FOR NOT COMPLY
Senin Selasa Rabu kamis Jumat Sabtu Minggu
1 Engine No spark (mudah di start, tidak ada percikan)
2 Fuel tank No leak (tidak bocor)
3 Fuel tank cover As manufacturing standard (sesuai dengan standar
pabrikan)
4 Battery cover Cover all surface made from isolator material ex.
rubber (menutupi seluruh permukaan dengan
material isolator, cth. rubber)
5 Engine control switch Easy for start&stop (mudah untuk start&stop)
6 Connection plug Tight,not leak (rapat,tidak bocor)
7 Cable internal As manufacturing standard (sesuai dengan standar
pabrikan) and as per volt & current (volt dan arus)

8 Motor housing Tight (rapat)

9 Emergency stop Work,common visualization (berfungsi,terlihat
secara umum)
10 Panel indicator Work (berfungsi)
11 Plug & Primary cable Connection is good and no burn (sambungan bagus
dan tidak terbakar)
12 Welding cable extention Female and Male connection are fully insulated
(sambungan laki dan perempuan terisolasi penuh)
and no damage (tidak ada rusak)

13 Grouding terminal Availlable,work (tersedia,berfungsi)

14 Current Electrical As per specification
15 Voltage Reduction Device (VRD) Good function (fungsinya baik)
16 Fire extinguisher Available (tersedia)

OPERATOR
SIGNED BY
LEADER
REMARKS

Welding Machine

BG-06221IDa2.xlsx
 Security Level 2
BG-06221ID
Appendix (2)-
74 /89
Form No.: Form-I-063
Inspection Date :
ELECTRIC AIR COMPRESSOR Location of Inspection :
Company/Subcontractor :

INSPECTION STANDARD Validty of inspection :

ID NO: Seri No. :
Type of inspection : Monthly for High Risk/ every 3 Months
(PP/50/2012 & CAL/OSHA 29 CFR 1910)
INSPECTION METHOD INSPECTION RESULT
No INSPECTION ITEM STANDARDS REASON FOR NOT COMPLY
VISUAL FUNCTION IKPT CLIENT
1 Knop Of The Pressure Swith Available & Good Funciton (Ada dan Berfungsi Baik) ● ●

2 Knop Of The Pressure Reducer Available & Good Funciton (Ada dan Berfungsi Baik) ●

3 Intake Filter Available & Good Funciton (Ada dan Berfungsi Baik) ●

4 Head Good Condicition (Baik dan Tidak Bocor) ●

5 Dipstick Good Condicition (Baik dan Tidak Bocor) ●

6 Tank Good Not Leak (Tidak Bocor) ●

7 Wheel Good Condition (Dalam Kondisi Baik) ● ●

8 Drain Cock Available & Good Funciton (Ada dan Berfungsi Baik) ●

9 Join Available & Good Funciton (Ada dan Berfungsi Baik) ● ●

10 Cable Connector Not Peeled and Cracked (Tidak Terkelupas dan Retak) ●

11 Accecoris Available PI ●

12 Test Run NO Vibration & No Spack(Vibrasi Kecil dan Tidak ada Percikan Listrik) ●

INSPECTION STATUS

PASSED

HOLD

REJECTED

INSPECTION DURATION : To

SPECIAL NOTE FROM CLIENT :

INSPECTED BY APP ROVED BY

Name and Signature Name and Signature

Stiker Number

Stiker Number

Stiker Number

BG-06221IDa2.xlsx
 Security Level 2
BG-06221ID
Appendix (2)-
75 /89
Form no.: Form-I-064
Inspection Date :
CHAIN SAW Location of Inspection :
Company/Subcontractor :

INSPECTION STANDARD Validty of inspection :

ID NO: Seri No. :
Type of inspection : Monthly for High Risk/ every 3 Months
(PP/50/2012 & OSHA 1910.243)
INSPECTION METHOD INSPECTION RESULT
No INSPECTION ITEM STANDARDS REASON FOR NOT COMPLY
VISUAL FUNCTION IKPT CLIENT
1 front guard not crack,tight (tidak retak,rapat) ●
2 front handle vibration shock,oil free (tahan terhadap getaran,tidak ada ●
minyak)
3 muffeler and sparks arrestor not spark,crack.tight(tidak ada percikan api,retak.rapat) ● ●
4 spike bumper tight,not crack (rapat,tidak retak) ●
5 guide bar not crack(tidak retak) ●
6 guide bar cover not crack(tidak retak) ●
7 chain catcher not crack,tight (tidak retak,rapat) ●
8 anti-vibration system work (berfungsi) ●
9 rear hand guard anti shock ●
10 rear handle available,anti shock ●
11 throttle tringger as manufacturing standard (sesuai dengan standar pabrikan) ●

12 throttle trigger lockout(interlock) work (berfungsi) ●

13 fuel tank no leak (tidak bocor) ●

14 saw chain tight,lubricated,no corrosive(rapat,terlumasi,tidak karat) ● ●
15 fuel tank cover tight as manufacturing standard(rapat sesuai dengan standar ●
pabrikan)

INSPECTION STATUS
PASSED

HOLD

REJECTED

SPECIAL NOTE FROM CLIENT :

INSPECTED BY APPROVED BY

Name and Signature Name and Signature

Stiker Number

Stiker Number

Stiker Number

BG-06221IDa2.xlsx
 Security Level 2
BG-06221ID
Appendix (2)-
76 /89

Form No. : Form-I-065

Inspection Date :
GRINDING Location of Inspection :
Company/Subcontractor :
INSPECTION STANDARD Validty of inspection :
ID NO: Seri No. :
Type of inspection : Monthly for High Risk/ every 3
( SHA 29 CFR 1910)
INSPECTION METHOD INSPECTION RESULT
No INSPECTION ITEM STANDARDS REASON FOR NOT COMPLY
VISUAL FUNCTION IKPT CLIENT
1 Side handle Availlable (tersedia) ●
2 Wheel guard Not crack (tidak retak) ●
3 Wheel lock Nut not crack,tight (baut tidak retak,rapat) ●
4 Wrench Availlable (tersedia) ●
5 Spidle lock button Work (berfungsi) ● ●
6 Switch Work (berfungsi) ●
7 Wheel As manufacturing standard, not expired (sesuai dengan ●
standar
8 Dead Man switch Work (berfungsi) ●
9 Body machine Not greased,oil (tidak ada grease,oli) ●
10 Power cord Not scratch,insullated (tidak sobek,terisolasi) ●
11 Motor No spark (tidak ada percikan) ●

INSPECTION STATUS

PASSED

HOLD

REJECTED

SPECIAL NOTE FROM CLIENT :

INSPECTED BY APP ROVED BY

Name and Signature Name and Signature

Stiker Number

Stiker Number

Stiker Number

BG-06221IDa2.xlsx
 Security Level 2
BG-06221ID
Appendix (2)-
77 /89

Form No. : Form-I-066

Inspection Date :
HAND DRILL Location of Inspection :
Company/Subcontractor :
Validty of inspection :

INSPECTION STANDARD ( PP/50/2012 & OSHA 29 CFR 1910)

ID NO: Seri No. :
Type of inspection : Monthly for High Risk/ every

INSPECTION METHOD INSPECTION RESULT

No INSPECTION ITEM STANDARDS REASON FOR NOT COMPLY
VISUAL FUNCTION IKPT CLIENT
1 Housing No Crack(tidak retak) ●

2 Gear Cover Installed Properly (Terpasang dgn benar) ●

3 Drill Chuck Installed Properly & No worn out (Terpasang dgn benar & Tidak ● ●
Aus)
4 Switch Available & Easy to Push (Ada dan Mudah ditekan) ● ●

5 Dead Man Switch

Available & Easy to Push (Ada dan Mudah ditekan) ● ●

6 Handle Cover Sturdy and No Crack (Kokoh dan Tidak Retak) ●

7 Stopper Available & Good Function (Ada dan Berfungsi Dengan Baik) ● ●

8 Reverse Switch Available & Easy to Push (Ada dan mudah ditekan) ● ●

9 Cable & Socket Not Peeled and No Crack, proper gounding (Tidak Terkelupas ●
, Tidak Retak ,grounding bagus)

10 Test Run No Spark from engine (Tidak ada Percikan Listrik) ● ●

INSPECTION STATUS

PASSED

HOLD

REJECT

SPECIAL NOTE FROM CLIENT:

INSPECTION BY APPROVED BY

Name and Signature Nameand Signature

Stiker Number

Stiker Number

Stiker Number

BG-06221IDa2.xlsx
 Security Level 2
BG-06221ID

Appendix (2)-
Form No.: Form-I-068

Inspection Date :
CUT - OFF MACHINE Location of Inspection :
Company/Subcontractor :
Validty of inspection :
INSPECTION STANDARD ID NO: Seri No. :
Type of inspection : Monthly for High Risk/ every 3 Months
(P/50/2012 & OSHA 29 CFR 1910)
No INSPECTION ITEM STANDARDS INSPECTION METHOD INSPECTION RESULT REASON FOR NOT COMPLY
VISUAL FUNCTION IKPT CLIENT
1 handle Free from oil (bebas dari minyak) ●
2 cover disc Not crack,tight (tidak retak,rapat) ●
3 disc Not crack,tight,as manufacturing using guidence ●
(tidak retak,rapat,sesuai dengan petunjuk pemakaian)
4 safety chain Installed (terpasang) ●
5 electrical switch work (berfungsi) ● ●
6 motor Not spark,work (tidak ada percikan,berfungsi) ●
7 cover belt motor *if any covering surface (menutupi permukaan) ●
8 cut-off stand Not crack (tidak retak) ●
9 object lock work (berfungsi) ● ●

INSPECTION STATUS

PASSED

REJECT

HOLD

SPECIAL NOTE FROM CLIENT :

INSPECTED BY APP ROVED BY

Name and Signature Name and Signature

Stiker Number

Stiker Number

Stiker Number

BG-06221IDa2.xlsx
 Security Level 2
BG-06221ID

Appendix (2)-
Form No.: Form-I-068

ELECTRICAL LIGHTING
Inspection Date :
Location of Inspection :
Company/Subcontractor :
Validty of inspection :

INSPECTION STANDARD ID NO: Seri No. :

Type of inspection : Monthly for High Risk/ every 3 Months
(PP/50/2012 & OSHA 1910.243)
Capacity:
Type of Equipment : Non CSE Lighting CSE Lighting

INSPECTION METHOD INSPECTION RESULT

No INSPECTION ITEM STANDARDS REASON FOR NOT COMPLY
VISUAL FUNCTION IKPT CLIENT
1 Hard cover Installed,tight (terpasang,rapat) ●
2 Type of lamp Ex (explotion proof), type min.IP 54(tipe explotion ●
proof,min.IP54)
3 Stand lamp Free from oil spill (bebas dari tumpahan minyak) ●
4 Cable for non CSE lighting Suitble for function outdoor/indoor,no scratch (sesuai ●
dengan fungsinya diluar/didalam,tidak robek)

5 Plug Min.IP.54 ●
6 Body lamp Free from oil,no crack(bebas dari oli,tidak retak) ●
7 Voltage lamp Max.24volt ●
8 Cable for CSE lighting No scratch,every connection using juntion box(tidak ●
robek,setiap sambungan menggunakan junction
box)
9 Hanger Free from oil(bebas dari minyak) ●
10 Cover lamp No damage, coverage glass surface (tidak rusak) ●

INSPECTION STATUS SPECIAL NOTE FROM CLIENT :

INSPECTED BY APPROVED BY

Name & Signature Name & Signature

Non CSE Lighting CSE Lighting

PASSED

REJECT

HOLD
Stiker Number

Stiker Number

BG-06221IDa2.xlsx
 Security Level 2
BG-06221ID

Appendix (2)-
Form No.: Form-I-069
Inspection Date :
ELECTRICAL ACCECORIS Location of Inspection :
Company/Subcontractor :

INSPECTION STANDARD Validty of inspection :

ID NO: Seri No. :
Type of inspection : Monthly for High Risk/ every 3 Months
(PP/50/2012 & OSHA 1910.243)
INSPECTION METHOD INSPECTION RESULT
No INSPECTION ITEM STANDARDS REASON FOR NOT COMPLY
VISUAL FUNCTION IKPT CLIENT
1 Cable insulated Manufacturing guide (outdoor/indoor) ●

2 Cable roll Gasproof,min.IP.44(anti-gas min.IP.44) ●

3 Junction box min.IP.44 ●

4 Grounding cable Max.hold 5ohm,insullated ●

5 Receptacle Min.IP.44 ●

6 Plug Min.IP.44 ●

7 Connection cable All cable connection using junction box ●

8 Grounding clamp Filamen conductor not damage,tight (filamen konduktor ●

tidak
9 ELCB Functioned (berfungsi) ● ●

INSPECTION STATUS
PASSED

REJECT

HOLD

SPECIAL NOTE FROM CLIENT :

INSPECTED BY APPROVED BY

Name and Signature Name and Signature

Stiker Number

Stiker Number

Stiker Number

BG-06221IDa2.xlsx
 Security Level 2
BG-06221ID

Appendix (2)-
Form No. Form-I-070
Inspection Date :
WELDING TRANSFORMER Location of Inspection :
Company/Subcontractor :
INSPECTION STANDARD Validty of inspection :
ID NO: Seri No. :
Type of inspection : Monthly for High Risk/ every 3 Months
(PP/50/2012 & OSHA 1910.243)
Type of Equipment : Welding Trafo Inverter Capacity :
INSPECTION METHOD INSPECTION RESULT
No INSPECTION ITEM STANDARDS REASON FOR NOT COMPLY
VISUAL FUNCTION IKPT CLIENT
1 Power Supply Swith ON/Off is Good (Fungsi Start Stop Baik)
●
2 Welding Current Adjust Available & Not Hard To Push (ada dan tidak
susah ●
3 Current Meter Must Be Available (Harus ADA)
●
4 Button Must be Available & Good Funciton
(Harus Ada dan Berfungsi Dengan Baik) ●
5 Fan Smooth (Putaran Baik dan Vibrasi Halus)
●
6 Cover Lock & Good (Terkunci Rapat dan Baik)
●
7 Welding contactor receptacle Have cover,min.IP54 (memiliki tutup,
min.IP54) ●
8 Circuit breaker Work,not damage,shortage test passed
(berfungsi,tidak rusak,lolos test shortage) ●

INSPECTION STATUS SPECIAL NOTE FROM CLIENT :

PASSED

HOLD INSPECTED BY APPROVED BY

REJECT
Name & Signature Name & Signature

Welding Inverter

Stiker Number

Stiker Number

BG-06221IDa2.xlsx
 Security Level 2
BG-06221ID

Appendix (2)-
Form No.: Form-I-071
Inspection Date :
WELDING ROD DRYER Location of Inspection :
Company/Subcontractor :
Validty of inspection :
INSPECTION STANDARD ID NO: Seri No. :
Type of inspection : Monthly for High Risk/ every 3 Months
(PP/50/2012 & OSHA 1910.243)
INSPECTION INSPECTION RESULT
No INSPECTION ITEM STANDARDS VISUAL FUNCTION IKPT CLIENT REASON FOR NOT COMPLY
1 Handle work (berfungsi) ● ●
2 Body Not crack (tidak retak)Not ●
Corrosive,Grounding
3 Cable Connection not molted,scratch(tidak melele,sobek) ● ●
4 Grounding Cable Max.hold 5 ohm,insullated ●
5 Socket IP.44 ●
6 Plug IP.44 ●

INSPECTION STATUS
PASSED

HOLD
Handle

REJECTE
Cable Body
D

Socket

SPECIAL NOTE FROM CLIENT :

INSPECTED BY APPROVED BY

Name and Signature Name and Signature

Stiker Number

Stiker Number

Stiker Number

BG-06221IDa2.xlsx
 Security Level 2
BG-06221ID
Appendix (2)-
Form no.: Form-I-072
83 /89

Inspection Date :
WINCH Location of Inspection :
Company/Subcontractor :

INSPECTION STANDARD Validty of inspection :

ID NO: Seri No. :
Type of inspection : Monthly for High Risk/ every 3 Months
(PER.05/MEN/1985 PESAWAT ANGKAT DAN ANGKUT)
Capacity :
Type of Equipment : POTABLE Attached on permanent body
INSPECTION METHOD INSPECTION RESULT
No INSPECTION ITEM STANDARDS REASON FOR NOT COMPLY
VISUAL FUNCTION OWNER CLIENT
1 Bed Plate sturdy and no crooked (kokoh dan tidak bengkok) ● ●
2 Oil Bath Sealed and tight (terlindungi dan rapat) ●
3 Gypsy Head Sturdy (kokoh ) ●
4 Drum Clutch Function properly and there is no strange sound (berfungsi dengan
● ●
baik dan tidak ada suara aneh)
5 Clutch lever easy to operate (mudah dioperasikan) ● ●
6 Drum Brake lever In good condition and easy to operate (dalam kondisi baik dan mudah
dioperasikan) ● ●
7 Electric Brake function properly (berfungsi dengan baik ) ● ●
8 Drum Brake Round smooth and not corrosion (bulat halus dan tidak korosi)
●

9 Drum Gear No crack and chipped (tidak ada retak dan bocel) ●
10 Reduction Gear Function properly and there is no strange sound (berfungsi dengan
●
baik dan tidak ada suara aneh)
11 Drum Round smooth and not corrosion (bulat halus dan tidak korosi)
●
12 Rope guard No broken and fragile fibers (Tidak ada serat yang rusak dan rapuh)
●
13 Reduction Gear Function properly and there is no strange sound (berfungsi dengan
● ●
baik dan tidak ada suara aneh)
14 Speed Control Function properly (berfungsi dengan baik ) ●
15 Sling No corrosive, crack, no broken (tidak berkarat,crack, tidak yang
putus) ●

16 Cable gland min.IP.44 ●

17 Cable Not scratch, well insulated , as manufacturing
●
instruction(Tidak terkelupas, terisolasi baik, sesuai dengan
18 Cable lug Tight (rapat) ● ●
19 Cable insulated As manufacturing guide (outdoor/indoor) ●
20 Junction box Gasproof, min.IP.44 (anti-gas min.IP.44) ●
21 Grounding cable Min.IP.44 ●
22 Receptable Max. hold 5 ohm, insulated ●
23 Connection cable Min.IP.44 ●
24 Grounding clamp Filamen conductor not damage, tight
●
(filamen konduktor tidak rusak, rapat)

INSPECTION STATUS SPECIAL NOTE FROM CLIENT :

PASSED

INSPECTED BY APPROVED BY
HOLD

REJECTED
Name & Signature Name & Signature

*Stiker Number

*Stiker Number

* Stiker Number

* For electrical assesoris not mandatory

BG-06221IDa2.xlsx
 Security Level 2
BG-06221ID
Appendix (2)-
Form no.: Form-I-072
84 /89

Inspection Date :
MOTOR HOIST Location of Inspection :
Company/Subcontractor :

INSPECTION STANDARD Validty of inspection :

ID NO: Seri No. :
Type of inspection : Monthly for High Risk/ every 3 Months
(PER.08/MEN/2020 PESAWAT ANGKAT DAN PESAWAT ANGKUT)
Capacity :
Type of Equipment :
INSPECTION METHOD INSPECTION RESULT
No INSPECTION ITEM STANDARDS REASON FOR NOT COMPLY
VISUAL FUNCTION OWNER CLIENT
1 Shell/Support sturdy and no crooked (kokoh dan tidak bengkok) ●
2 Support Frame Not deformed and Sturdy (tidak cacat dan kokoh) ●
3 Transformer Sealed and tight (terlindungi dan rapat) ● ●
4 Electromagnetic contactor Good condtion (kondisi baik) ●
5 Mechanic braker dual braking In good condition and easy to operate (dalam kondisi baik dan mudah
● ●
dioperasikan)
6 Inverse phase sequence protecting In good condition and easy to operate (dalam kondisi baik dan mudah
● ●
device dioperasikan)
7 Side magnetic baking device In good condition and easy to operate (dalam kondisi baik dan mudah
dioperasikan) ●
8 Limit switch function properly (berfungsi dengan baik ) ● ●
9 Chains No crack,bent,stretched,heat damage (tidak retak,bengkok,rusak
●
karena panas)
10 Hook Safety lack work,no bent (pengunci berfungsi,tidak bengkok) ●
11 Push botton Function properly (berfungsi dengan baik ) ● ●
12 Cable Not scratch, well insulated , as manufacturing
●
instruction(Tidak terkelupas, terisolasi baik, sesuai dengan
13 Junction box Min.IP.44 (Min.IP.44) ●

INSPECTION STATUS SPECIAL NOTE FROM CLIENT :

PASSED
INSPECTED BY APPROVED BY
HOLD

REJECTED
Name & Signature Name & Signature

*Stiker Number

*Stiker Number

* Stiker Number

* For electrical assesoris not mandatory

BG-06221IDa2.xlsx
 Security Level 2
BG-06221ID
Appendix (2)-85/89
Form No. : Form-I-081
Inspection Date :
SAFETY BODY HARNESS Location of Inspection :
Company/Subcontractor :
INSPECTION STANDARD Validty of inspection :
ID NO: Seri No. :
Type of inspection : Monthly for High Risk/ every 3 Months
INSPECTION METHOD INSPECTION RESULT
No. INSPECTION ITEM STANDARDS REASON FOR NOT COMPLY
VISUAL FUNCTION IKPT CLIENT
1 Manufacture Name : ●
Hadware
1 Snap Hooks Tidak retak, mudah dioprasikan, tidak
● ●
karat
2 D-Ring Tidak retak, korosi. ●
3 Carabiner Tidak retak, korosi, mudah di operasikan ● ●
4 Webbing Tidak ada yang robek, terbakar, lobang.
Bersih dari oli/cairan kimia apapun. ●

5 Stitcing (JAHITAN) Jahitan tidak ada yang terlepas ●

6 Lanyard untuk absorber masih terbungkus dengan ●
7 Label Masih terpasang ●
8 Rope (Tali) opsional Lilitan tidak rusak, robek / terbakar.
Bersih dari oli / cairan kimia ●
apapun.

INSPECTION STATUS

PASSED

HOLD

REJECTED

SPECIAL NOTE FROM CLIENT :

INSPECTED BY APPROVED BY

Name & Signature Name & Signature

BG-06221IDa2.xlsx
 Security Level 2
BG-06221ID
Appendix (2)-86/89

Form N Form-I-082
Inspection Date :
FIRE EXTINGUISHER Location of Inspection :
Company/Subcontractor :
INSPECTION STANDARD Validty of inspection :
ID : FE - …...
Type of inspection : Weekly
REASON FOR
No. INSPECTION ITEM STANDARDS BY WEEKLY INSPECTION NOT COMPLY
Date:
1 Manufacture Name:
2 Label
Type (Water, CO2, Dry Chemical) Clearly (jelas)
Classsification (A, B, C) Clearly (jelas)
NFPA Capacity Rating Clearly (jelas)
Instruction Clearly (jelas)
3 Powder/inside content Still inside
3 Locking Pin Available and easy to operated
4 Carryig handle No rusty and no bent
5 Pressure gauge Clearly and on green indicator
6 Discharge Nozzle and hose no broken and no leak

IKPT INSPECTOR
INSPECTION STATUS
CLIENT INSPECTOR

BG-06221IDa2.xlsxs
 Security Level 2
BG-06221ID

Appendix (2)-
Form No. : Form-I-090
Inspection Date :
Location of Inspection :
Company/Subcontractor :
STAMPER INSPECTION STANDARD Validty of inspection :
ID NO: Seri No. :
Type of inspection : Monthly for High Risk/ every 3 Months
INSPECTION METHOD INSPECTION RESULT
No. INSPECTION ITEM STANDARDS REASON FOR NOT COMPLY
VISUAL FUNCTION IKPT CLIENT
1 Fuel cap (tutup bahan bakar) Tight,as manufacturing standard ● ●
(rapat,sesuai standar pabrikan)
2 Fuel tank (tangki bahan bakar) Not leak (tidak bocor) ●
3 Gas Level (Tuas Gas) work (Berfungsi dengan baik) ● ●
4 Handle work (Tidak karat) ●
5 Cable Gas work (Berfungsi dengan baik) ● ●
6 Handle stater work (Berfungsi dengan baik,On/Off) ●
7 Engine (Mesin) work,No leak,noise (berfungsi,tidak bocor, ● ●
8 Cylinder Cover work (Berfungsi dengan baik) ● ●
9 Plate shoes work (Berfungsi dengan baik,baut ● ●
terpasang dengan baik)
10 Head,brake,signal light (Lampu Good Function (Berfungsi dengan baik) ● ●
besar, rem, sein)
11 Cabin indicator (Indikator pada Good Function (Berfungsi dengan baik) ● ●
kabin)
12 Wiper Good Function (Berfungsi dengan baik) ● ●
13 Emision (Emisi gas buang) Graduated from the Department of ●
transportation.

INSPECTION STATUS
Fuel Cap
PASSED Fuel Tank

HOLD
Gas Level

REJECTED

Handle

SPECIAL NOTE FROM CLIENT: Engine

INSPECTION BY APPROVED BY
Handle Starter Plate Stamper

Name and Signature Name and Signature

BG-06221IDa2.xlsx
 Security Level 2
BG-06221ID
Appendix (2)-
Form No. : Form-I-092
88 /89
Inspection Date :
CUTTING TORCH Location of Inspection :
Company/Subcontractor :

INSPECTION STANDARD Validty of inspection :

ID NO: Seri No. :
Type of inspection : Monthly for High Risk/ every 3 Months
(PP/50/2012 & OSHA 1910.243)
INSPECTION METHOD INSPECTION RESULT
No INSPECTION ITEM STANDARDS REASON FOR NOT COMPLY
VISUAL FUNCTION IKPT CLIENT
1 cylinder bottol not crack,leak,corrosive (tidak retak,bocor,karat) ●
2 check valve installed 2 ea after regullator and before stang torch (terpasang ●
2
setelah regulator dna sebelum stik)
3 hose not abrasive,crack (tidak abrasif,retak) ●
4 hose connection tight (rapat) ●
5 regullator installed,industrial standard,pressure gauge not broken ● ●
(terpasang,standar industri,pengukur tekanan tidak rusak)
6 stick work (berfungsi) ●
7 lighter using industrial standard not fuel lighter (standard industri tidak ●
menggunakan bahan bakar)
8 Fire extinghuiser min. 6 Kg ● ●
9 wrench availlable,hanging on cradle(tersedia,digantung di cradle) ●
10 cylinder cap availlable (tersedia) ●
11 cradle ●
as manufacturing standard (sesuai dengan standar pabrikan)

12 cylinder labled installed,clear as GHS standard (terpasang,jelas sesuai dengan ●

standar GHS)
13 stick housing not damage (tidak rusak) ●

INSPECTION STATUS

PASSED

HOLD

REJECTE

SPECIAL NOTE FROM CLIENT :

INSPECTED BY APPROVED BY

Name and Signature Name and Signature

Stiker Number

Stiker Number

Stiker Number

BG-06221IDa2.xlsx
 Security Level 2
BG-06221ID
Appendix (2)-
Form No. : Form-I-092
89 /89
Inspection Date :

MANUAL HYDRAULIC Location of Inspection :

Company/Subcontractor :
Validty of inspection :

INSPECTION STANDARD ID NO: Seri No. :

Type of inspection : Monthly for High Risk/ every 3 Months

INSPECTION METHOD INSPECTION RESULT

No INSPECTION ITEM STANDARDS REASON FOR NOT COMPLY
VISUAL FUNCTION IKPT CLIENT
1 Pump Oil No leak,level normal condition (tidak ● ●
bocor,level normal)
2 Handle Pump work properly (berfungsi dengan baik)
3 Gauge Pressure available and work properly (ada, ● ●
berfungsi dengan baik )
4 Hose No leak ●
5 Connection Hose No crack,Leak (Tidak retak,bocor) ●
6 Cylinder No crack,Leak (Tidak retak,bocor) ●

INSPECTION STATUS
PASSED CYINDER
HOSE

HOLD
CONNECTION HOSE
REJECTED

SPECIAL NOTE FROM CLIENT:

HANDLE PUMP

Pressure Indicator
INSPECTED BY APPROVED BY

OIL CAP
Name and Signature Name and Signature
Stiker Number

Stiker Number

Stiker Number

BG-06221IDa2.xlsx
 Security Level 2

BG-06221ID
EQUIPMENT & TOOLS INSPECTIONS HISTORY
PAGE 1 OF 1

･ISSUE DATE
REV. ･ISSUE GRADE DESCRIPTION
･AUTHORIZATION
0 FEB.10,'15 (1) Background and Reasons for Revision
Documentation Code (a) According to SQE Promotion Committee #75 article No.4, it was decided that
changed for the Documentation Code of TGS/JLS shall be changed into Global Standards
Group Standards & (GS) & Local Standards (LS).
Local Standards (b) This document is revision of DP-SHE-032 which had been abolished.
(c) Revision of Appendix (1), Crane Carry-in Inspection, load indicator revision
on section number 12.
SHES Department (2) Department and Author SHES Dept. Ahmad Syauqi
1 MAR.25,'19 (1) Background and Reasons for Revision
Revision of Appendix (1) and (2), change of All Inspection form and additional
Wholly Revised of inspection form.
(2) Department and Author SHES Dept. Ahmad Syauqi
SHES Department
2 AUG.19,'21 (1) Background and Reasons for Revision
Revision of Appendix (2), change of Inspection form related to Lifting
Partly Revised equipment and Accessories.
(2) Department and Author SHES Dept. Wildan Ramdan R.
SHES Department

BG-06221IDr.doc