Form Checklist Inspeksi Scaffolding [PDF]

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SCAFFOLDING INSPECTION CHECK LIST LOCATION SCAFFOLDING TYPE



:



MAX LOAD CONSTRUCTED



: :



:



GENERAL SCAFFOLD : DATE



NO ITEM TO BE INSPECTION 1 Apakah pipa standard perancah mempunyai plat dasar 2 Semua plat dasar pipa standard benar-benar kuat 3 Apakah pipa standard tegak lurus/level 4 Apakah standard mempunyai jarak yang tetap 5 Apakah sambungan dipipa standard telah benar 6 Apakah ledger level 7 Apakah tarnsom level 8 Apakah tinggi perancah benar (2 meter maksimal) 9 Apakah perancah diikat pada tingkat/level yang ke tiga 10 Dan disetiap dua tingkat berikutnya 11 Apakah bangunan perancah kokoh 12 Jalan untuk akses tersedia dan terikat ditingkat yang teratas 13 Papan kayu untuk bekerja tersedia 14 Lebar papan kayu minimal 40 cm 15 Papan kayu aman dan terikat 16 Apakah handrail tersedia 17 Apakah perancah level & tegak lurus 18 Apakah clamp pengaman sudah terpasang 19 Apakah scaffolding aman untuk dipergunakan



DESCRIPTION : USER : Company



OK



: NOK



REMARK



INSPECTION BY : Safety Dept.



Rigging Dept.



Date of Inspection



INSPECTION LIST FOR FIRE PREVENTIVE Date



: ELECTRICAL (MAIN OFFICE LINE)



NO



ITEM



OK



NOK



REMARK



1 Transformer 3 Pass 2 Main Panel 3 4 5 6 7 8 9 10 11 12 13



Sub Panel Main Line Sub Distributor Line Main Circuit Breaker Sub Circuit Breaker Cable Condition Sub Distribution Cable Fuse How Many panel Position of Cable Fire Extinguisher



Inspected By, Safety



___________



Electrician,



___________



Engineering,



____________



Q.C,



______________



INSPECTION FIRE EQUIPMENT FOR PREVENTIVE No



Location



Type



Size Kg/Lt



Date Service



Expired



Inspection Weekly Monthly



6,8 Kg. 6 Kg. 6 Kg. 6 Kg.



10/1/2001 10/1/2001 10/1/2001 10/1/2001



10/1/2002 10/1/2002 10/1/2002 10/1/2002



4/8/2002 4/8/2002 4/8/2002 4/8/2002



6 Kg 6 Kg 6 Kg



10/1/2001 10/1/2001 10/1/2001



10/1/2002 10/1/2002 10/1/2002



4/8/2002 4/8/2002 4/8/2002



Remark



A



Tool Room



1. CO2 2. DC 3. DC 4. DC



B



Work Shop Wall



1. DC 2. DC 3. DC



C



Mechanic Room



1. Foam 2. DC 3. CO2



9 Lt 6 Kg 6,8 Kg



10/1/2001 10/1/2001 10/1/2001



10/1/2002 10/1/2002 10/1/2002



4/8/2002 4/8/2002 4/8/2002



D



Ware House



1. Foam 2. CO2 3. CO2 4. DC 5. DC 6. DC



9 Lt 6,8 Kg 6,8 Kg 6 Kg 40 Kg 40 Kg



10/1/2001 10/1/2001 10/1/2001 10/1/2001 10/1/2001 10/1/2001



10/1/2002 10/1/2002 10/1/2002 10/1/2002 10/1/2002 10/1/2002



4/8/2002 4/8/2002 Hose must be replace 4/8/2002 4/8/2002 4/8/2002 4/8/2002



E



Power House



1. DC



6 Kg



10/1/2001



10/1/2002



4/8/2002



F



Roll Machine



1. DC



6 Kg



10/1/2001



10/1/2002



4/8/2002



c:\excel\form Inspection List



INSPECTION FIRE EQUIPMENT FOR PREVENTIVE No



Location



Type



Size Kg/Lt



Date Service



Expired



Inspection Weekly Monthly



G



Gantry Crane I



1. DC



6 Kg



10/1/2001



10/1/2002



4/8/2002



H



Kitchen Room



1. DC



6 Kg



10/1/2001



10/1/2002



4/8/2002



I



Personnel Dept.



1. CO2



6,8 Kg



10/1/2001



10/1/2002



4/8/2002



J



Accounting Dept.



1. CO2



4,4 Kg



10/1/2001



10/1/2002



4/8/2002



K



Reception Room



1. CO2



4,4 Kg



10/1/2001



10/1/2002



4/8/2002



Inspected By,



Inspected By,



_________ HSE Dept.



_______________ Ware House Dept.



c:\excel\form Inspection List



Remark