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FM - Hse.mbl.004. Komissioning Dump Truck

This document is a commissioning form for a dump truck. It contains 25 items that are checked such as the vehicle body, tires, doors, lights, safety equipment, engine and more. For each item, it is marked as suitable or unsuitable and any notes can be added. At the bottom, the results of the commissioning are recorded as suitable for operation or not suitable, and it requires signatures from the contractor, mechanic, HSE head and KTT to approve.

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richo naiborhu
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187 views1 page

FM - Hse.mbl.004. Komissioning Dump Truck

This document is a commissioning form for a dump truck. It contains 25 items that are checked such as the vehicle body, tires, doors, lights, safety equipment, engine and more. For each item, it is marked as suitable or unsuitable and any notes can be added. At the bottom, the results of the commissioning are recorded as suitable for operation or not suitable, and it requires signatures from the contractor, mechanic, HSE head and KTT to approve.

Uploaded by

richo naiborhu
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
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PT.

MANOOR BULATN LESTARI


FORMULIR KOMISSIONING DUMP TRUCK

Tanggal Komissioning/Date :_____________ KM/HM :______________


Tipe Unit/Type Unit :_____________ Perusahaan/Campany :______________
No. Kendaraan/No.Plat :_____________ Akses Jalan /Road Access :______________
No.Mesin/No.Engine :_____________

LAYAK TIDAK
No ITEM YANG DIPERIKSA LAYAK KETERANGAN
1 Body Unit, Nomor Lambung
2 Ban dan Baut Nut/Tire and Bolt-Nut
3 Pintu Kabin (Cabin door)
4 No.unit Jelas jarak 100 mtr
5 Kaca Spion kiri & kanan
6 Wipers &Washer
7 Hydroulic
8 Kebocoran Oli (Fuid Leakage)
9 Battery /Accu
10 Tempat Duduk (Seat)
11 Sabuk Pengaman (Seat Belt)
12 Radio Komunikasi Rig
13 Kaca Spion kiri dan kanan /Mirror
14 Panel Indikator & Gauge
15 Kotak P3K (First Aid Box)
16 APAR 5 kg
17 Rem parkir/ Parking Brake
18 Fungsi Selang (Hose)
19 Klakson (Horn)
20 Alarm Mundur
21 Lampu Rem, Sein & Hazard
22 Lampu Rotary Blitz (>30 Watt)
23 Lampu Depan (Head Light)
24 Mesin (Engine)
25 Safety Cone (2 pcs)

Note :

HASIL KOMISSIONING / Result Commissioning

Layak Dioperasikan/Good to operation Tidak Layak Dioperasikan/ No Good to operation

Prepare By, Chack By, Know By, Approve By,

Kontraktor/Rental Mekanik HSE Head KTT

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