Cirebon 2, 1x1000MW Coal Fired Power Plant Project

GAS CUTTING / WELDING APPARATUS INSPECTION

Reference : Doc. No. Form - 015 Rev. 1

Date of Inspection Re-inspection

Equipment data : Operator data :

Registration Number Name

Manufacture Sex (male/female)

Serial Number Age

Capacity Position

Certificate Exp.

Subject : Gas cutting / Welding apparatus ………

Result column : Yes/good, Acceptable X Not/Bad, Not To Use NA Not Applicable

Copy of Driving license, Operator certificate and Equipment certificate must be attached in this form

NO CHECK ITEM CHECK POINTS RESULT REMARKS

1 Gas cylinder
* Appearance / Structure Damage, Deffect
* Indication Manufacturer, Pressure
* Installation Up-right position
* Caps/ Valve guard Missing

2 Regulator / Hoses / Torches

* Regulator Breakage
* Hoses / Connector Damage, Leakage
* Torches Breakage
* Flash back arrestor Function, Breakage

3 Misscellaneous
* Fire extinguisher Breakage, Missing
* Fire prevention Remove / Cover of flammables
* Overturn prevention Building / Carrer
* Provision of soap liquid Missing
* Sun shade (keep below 400C) Missing

Comments :

Inspected by,

C:/ayajid\form\cevtminsp.xls Page : 1 of 36
 ( __________________ ) ( __________________ )
Safety Officer Store Controller

C:/ayajid\form\cevtminsp.xls Page : 2 of 36
 Cirebon 2, 1x1000MW Coal Fired Power Plant Project

CONVEYOR INSPECTION
Reference : Doc. No. Form - 014 Rev. 0

Date of Inspection Re-inspection

Equipment data : Operator data :

Registration Number Name

Manufacture Sex (male/female)

Serial Number Age

Capacity Position

Certificate Exp.

Subject : Belt conveyor Screw conveyor ………

Result column : Yes/good, Acceptable X Not/Bad, Not To Use NA Not Applicable

Copy of Driving license, Operator certificate and Equipment certificate must be attached in this form

NO CHECK ITEM CHECK POINTS RESULT REMARKS

1 Engine
* Appearance / Structure Damage, Deffect
* Cooling system Water vol., V-belt, Fan
* Fuel system Pump, Pipe, Leakage
* Exhaust system Muffler, Sound
* Battery Liquid volume, Aging, Terminal
* Starter motor / Dynamo Function, Damage, Missing
* Emergency stopper Function, Damage, Missing

2 Motor
* Operating status Abnormal sound, Overheat
* Cable / Connector Breakage, Weather-proof
* Switch Function, Breakage
* V-belt Function, Breakage

3 Misscellaneous
* Safe guard for moving part
* Belt
* Belt cover

Comments :

Inspected by,

C:/ayajid\form\cevtminsp.xls Page : 3 of 36
 ( __________________ ) ( __________________ )
ME2- Safety Officer Mech. Supv./ Site Eng.

C:/ayajid\form\cevtminsp.xls Page : 4 of 36
 Cirebon 2, 1x1000MW Coal Fired Power Plant Project

AIR COMPRESSOR INSPECTION

Reference : Doc. No. Form - 013 Rev. 0

Date of Inspection Re-inspection

Equipment data : Operator data :

Registration Number Name

Manufacture Sex (male/female)

Serial Number Age

Capacity Position

Certificate Exp.

Subject : Air compressor ………

Result column : Yes/good, Acceptable X Not/Bad, Not To Use NA Not Applicable

Copy of Driving license, Operator certificate and Equipment certificate must be attached in this form

NO CHECK ITEM CHECK POINTS RESULT REMARKS

1 Engine
* Appearance / Structure Damage, Deffect
* Engine oil / Filter / Piping Pump, Pipe, Leakage
* Cooling system Water vol., V-belt, Fan
* Fuel system Pump, Pipe, Leakage
* Exhaust system Muffler, Sound
* Battery Liquid volume, Aging, Terminal
* Breaker / Automatic stopper Function, Damage, Missing
* Meters ( ampere / volt meters) Function, Breakage
* Wheels Structure, Wheel stopper
* Grounding Resistance, Missing
2 Generator
* Operating status Abnormal sound, Overheat
* Cylinder case Damage, Crack
* Housing Damage, Deformation
* Safety valve / Realase valve Function, Breakage
* Gauge (pressure / Temperatur) Function, Breakage
* Air receiver Damage, Leakage
3 Misscellaneous
* Safe guard for moving part

Comments :

Inspected by,

C:/ayajid\form\cevtminsp.xls Printed : 02/08/2024 at 04:07:49 Page : 5 of 36

 ( __________________ ) ( __________________ )

C:/ayajid\form\cevtminsp.xls Printed : 02/08/2024 at 04:07:49 Page : 6 of 36

 CIREBON 2, 1 X 1000 MW COAL FIRED POWER PLANT

POWER GENERATOR INSPECTION

Reference : Doc. No. Rev. 0

Date of Inspection Re-inspection

Equipment data : Operator data :

Registration Number Name

Manufacture Sex (male/female)

Serial Number Age

Capacity Position

Certificate Exp.

Subject : Power generator ………

Result column : Yes/good, Acceptable Not/Bad, Not To Use Not Applicable

Copy of Driving license, Operator certificate and Equipment certificate must be attached in this form

NO CHECK ITEM CHECK POINTS RESULT REMARKS

1 Engine
* Appearance / Structure Damage, Deffect
* Cooling system Water vol., V-belt, Fan
* Fuel system Pump, Pipe, Leakage
* Exhaust system Muffler, Sound
* Battery Liquid volume, Aging, Terminal
* Starter motor / Dynamo Function, Damage
* Breaker / Automatic stopper Function, Damage, Missing
* Meters ( ampere / volt meters) Function, Breakage
* Wheels Structure, Wheel stopper
* Grounding Resistance, Missing

2 Generator
* Operating status Quality, Capacity, Damage
* Transmission Quality, Capacity, Damage
* Carbon brush Water-proof, Damage
* Slip ring Damage, Secure, missing
* Outlet terminal / Wires
3 Misscellaneous
* Safe guard for moving part

Comments :

Inspected by, Approved By,

( __________________ ) ( __________________ )
Electrician LEW
 CIREBON 2, 1 X 1000 MW COAL FIRED POWER PLANT

POWER GENERATOR CHECKLIST

Equipment data : PERSON INCHARGE :
Registration Number Name :
Manufacture Position :
Serial Number Phone :
Capacity
Subject : Power generator ………
Result column : √ Yes/good, Acceptable X Not/Bad, Not To Use NA Not Applicable CHECK BY MECHANIC TEAM
NO CHECK ITEM CHECK POINTS Week 1 Week 2 Week 3 Week 4 REMARKS
1 Engine
* Appearance / Structure Damage, Deffect
* Cooling system Water vol., V-belt, Fan
* Fuel system Pump, Pipe, Leakage
* Exhaust system Muffler, Sound
* Battery Liquid volume, Aging, Terminal
* Starter motor / Dynamo Function, Damage
* Breaker / Automatic stopper Function, Damage, Missing
* Meters ( ampere / volt meters) Function, Breakage
* Wheels Structure, Wheel stopper
* Grounding Resistance, Missing
2 Generator
* Operating status Quality, Capacity, Damage
* Transmission Quality, Capacity, Damage
* Carbon brush Water-proof, Damage
* Slip ring Damage, Secure, missing
* Outlet terminal / Wires
3 Misscellaneous
* Safe guard for moving part
Note :
 Cirebon 2, 1x1000MW Coal Fired Power Plant Project

ELECTRICAL DISTRIBUTION BOARD INSPECTION

Reference : Doc. No. Form - 009 Rev. 0

Date of Inspection Re-inspection

Equipment data : Operator data :

Registration Number Name

Manufacture Sex (male/female)

Serial Number Age

Capacity Position

Certificate Exp.

Subject : Electrical distribution board ………

Result column : Yes/good, Acceptable X Not/Bad, Not To Use NA Not Applicable

Copy of Driving license, Operator certificate and Equipment certificate must be attached in this form

NO CHECK ITEM CHECK POINTS RESULT REMARKS

1 Electric distribution board
* Appearance / Structure Weather-proof, Door lock
* Earth leakage circuit breaker Function, Capacity
* Frame (body) earth Resistance, Damage, Missing
* Switches / Cover Breakage, Missing
* Socket / Outlet Breakage
* Light for night, Dim location Breakage, Missing
* Cable termination Secure, No exposed
* Installation Location, Access
* User's tag for each circuit Indication
* Door Lockable, Breakage
* Fire extinguiser Provision
* Warning sign for electrical shock Display
* Responsible persons Display
2 Misscellaneous
* Electrical bonding

Comments :

Inspected by,

( __________________ ) ( __________________ ) ( __________________ )

Electrician LEW Lead OF electrician LEW HDEC Construction Team

C:/ayajid\form\cevtminsp.xls Printed : 02/08/2024 at 04:07:49 Page : 11 of 36

C:/ayajid\form\cevtminsp.xls Printed : 02/08/2024 at 04:07:49 Page : 12 of 36
 CIREBON 2, 1 X 1000 MW COAL FIRED POWER PLANT

ELECTRICAL DISTRIBUTION CHECKLIST

Equipment data : PERSON INCHARGE :
Registration Number Name : Mr. Moon
Manufacture Position : HDEC electrical
Serial Number Phone : 0853-1532-5359
Capacity CHECK BY ELECTRICAL TEAM
Subject : Power generator ………
Result column : √ Yes/good, Acceptable X Not/Bad, Not To Use NA Not Applicable
NO CHECK ITEM CHECK POINTS Week 1 Week 2 Week 3 Week 4 REMARKS
1 Electric distribution board
* Appearance / Structure Weather-proof, Door lock
* Earth leakage circuit breaker Function, Capacity
* Frame (body) earth Resistance, Damage, Missing
* Switches / Cover Breakage, Missing
* Socket / Outlet Breakage
* Light for night, Dim location Breakage, Missing
* Cable termination Secure, No exposed
* Installation Location, Access
* User's tag for each circuit Indication
* Door Lockable, Breakage
2 * Fire extinguiser Provision
* Warning sign for electrical shock Display
* Responsible persons Display
3 Miscellenious
* Electrical bonding
Note :
 CIREBON 2, 1 X 1000 MW COAL FIRED POWER PLANT

WELDING ENGINE INSPECTION

Reference : Doc. No. Form - 011 Rev. 0

Date of Inspection Re-inspection

Equipment data : Operator data :

Registration Number Name

Manufacture Sex (male/female)

Serial Number Age

Capacity Position

Certificate Exp.

Subject : Welding engine ………

Result column : Yes/good, Acceptable X Not/Bad, Not To Use NA Not Applicable

Copy of Driving license, Operator certificate and Equipment certificate must be attached in this form

NO CHECK ITEM CHECK POINTS RESULT REMARKS

1 Welding engine
* Appearance / Structure Damage, Deffect
* Cooling system Water vol., V-belt, Fan
* Fuel system Pump, Pipe, Leakage
* Exhaust system Muffler, Sound
* Battery Liquid volume, Aging, Terminal
* Starter motor / Dynamo Function, Damage
* Breaker / Automatic stopper Function, Damage, Missing
* Meters ( ampere / volt meters) Function, Breakage
* Wheels Structure, Wheel stopper
* Grounding Resistance, Missing

2 Cable / Connector
* Supply cables Quality, Capacity, Damage
* Earth (return) cable Quality, Capacity, Damage
* Cable connectors Water-proof, Damage
* Cable terminals / Clamp Damage, Secure, missing

3 Misscellaneous
* Safe guard for moving part

Comments :

Inspected by, Approved by,

C:/ayajid\form\cevtminsp.xls Printed : 02/08/2024 at 04:07:49 Page : 14 of 36

 ( __________________ ) ( __________________ )
LEW Electrician

C:/ayajid\form\cevtminsp.xls Printed : 02/08/2024 at 04:07:49 Page : 15 of 36

 Cirebon 2, 1x1000MW Coal Fired Power Plant Project

ARC WELDING MACHINE INSPECTION

Reference : Doc. No. Form - 010 Rev. 0

Date of Inspection Re-inspection

Equipment data : Operator data :

Registration Number Name

Manufacture Sex (male/female)

Serial Number Age

Capacity Position

Certificate Exp.

Subject : ARC welding machine ………

Result column : Yes/good, Acceptable X Not/Bad, Not To Use NA Not Applicable

Copy of Driving license, Operator certificate and Equipment certificate must be attached in this form

NO CHECK ITEM CHECK POINTS RESULT REMARKS

1 ARC welding machine
* Appearance / Structure Damage, Deffect
* Operating status Abnormal sound, Overheat
* Frame (body) earth Resistance, Damage, Missing
* Skid / Wheels Structure, Wheel stopper
* Adjust handle Function, Damage
* Installation Stable, Securely, Height
* Automatic voltage reducer Function test, missing

2 Cable / Connector
* Supply cables Quality, Capacity, Damage
* Earth (return) cable Quality, Capacity, Damage
* Cable connectors Water-proof, Damage
* Cable terminals / Clamp Damage, Secure, missing
* Laying (not to be damaged) Overhung, Burried, Protection

3 Misscellaneous
* Safe guard for moving part

Comments :

Inspected by,

C:/ayajid\form\cevtminsp.xls Printed : 02/08/2024 at 04:07:49 Page : 16 of 36

 ( __________________ ) ( __________________ )
Electrician LEW HDEC Construction team

C:/ayajid\form\cevtminsp.xls Printed : 02/08/2024 at 04:07:49 Page : 17 of 36

 Cirebon 2, 1x1000MW
Coal Fired Power Plant Project

ELECTRICAL EQUIPMENT / TOOLS INSPECTION

Reference : Doc. No. Form - 000 Rev. 0

Date of Inspection Re-inspection

Equipment data : Operator data :

Registration Number Name

Manufacture Sex (male/female)

Serial Number Age

Capacity Position

Certificate Exp.

Subject : Saw Drill Cutter Grinder Blower Pump ………

Result column : Yes/good, Acceptable Not/Bad, Not To Use Not Applicable

Copy of Driving license, Operator certificate and Equipment certificate must be attached in this form

NO CHECK ITEM CHECK POINTS RESULT REMARKS

1 Equipment & tools
* Appearance Damage, Defects, Fixing
* Motor Abnormal sound, Overheat
* Safe guards Damage, Missing
* Earth for movable equipment Missing, Resistance
* Frame (body) earth Missing, Resistance
* Installation / Fixing Stable, Securely
* Abrasive disk / Blade Abrasion , Defect
* Hand switch Function, Damage, Location

2 Cable / Connector
* Cable / Insullation Quality, Capacity, Damage
* Cable connectors Water-proof, Damage
* Cable terminals / Clamp Damage, Secure, missing
* Laying (not to be damaged) Overhung, Burried, Protection

3 Misscellaneous

Comments :

Inspected by, Reviewed by, Approved by,

( __________________ ) ( __________________ ) ( __________________ )

Electrcian LEW Lead of electrician LEW HDEC Construction Team
 Cirebon 2, 1x1000MW Coal Fired Power Plant Project

GONDOLA / LIFT INSPECTION

Reference : Doc. Form - 007 Rev. 0

Date of Inspection Re-inspection

Equipment data : Operator / Driver data :

Registration Number Name

Manufacture Sex (male/female)

Serial Number Age

Capacity License / SIO

Certificate Exp. Expired

Subject : Gondola Cargo lift ……………

Result column : Yes/good, Acceptable X Not/Bad, Not To Use NA Not Applicable

Copy of Driving license, Operator certificate and Equipment certificate must be attached in this form

NO CHECK ITEM CHECK POINTS RESULT REMARKS

1 Overhang support arms
2 Wire ropes / Shackle Operability, Play
3 Reel winding / Sheaves Tire pressure, Abrasion
4 Electro / Mechanic Brakes Operating check, Play
5 Hand control devices Operating check
6 Stopper / Latches Reverse alarm, Turn signal
7 Cage / Handrail Head, Tail, Brake light
8 Bolts / Nuts / Bearings Damage, Missing
9 Control panel
10 Motor Operating check, Play
11 Cabtire cable / Earth Operating check, Play
12 Over wind warning devices Operating check
13 Emergency stopper Operating check
14 Lift : Guide rails / Supports Operating check
Shutering doors Door latch, Hand rails
15 Safe guard for moving parts Level, Smooth operation
Warning sign Indication
Weight / Person No. Limitation Indication

Comments :

Inspected by,

C:/ayajid\form\cevtminsp.xls Printed : 02/08/2024 at 04:07:49 Page : 19 of 36

 ( __________________ ) ( __________________ )
ME2 - Safety Officer Mech.Spv./ Site Eng.

MEI - Safety Officer SEMPEC - HSE Officer SEMPEC HSE Manager

C:/ayajid\form\cevtminsp.xls Printed : 02/08/2024 at 04:07:49 Page : 20 of 36

 Cirebon 2, 1x1000MW Coal Fired Power Plant Project

MOBILE LIFT INSPECTION

Reference : Doc. No. Form - 006 Rev. 0

Date of Inspection Re-inspection

Equipment data : Operator / Driver data :

Registration Number Name

Manufacture Sex (male/female)

Serial Number Age

Police Number (if any) License / SIO

Capacity Expired

Certificate Exp.

Subject : Telescope lift Scissors lift ……………

Result column : Yes/good, Acceptable X Not/Bad, Not To Use NA Not Applicable

Copy of Driving license, Operator certificate and Equipment certificate must be attached in this form

NO CHECK ITEM CHECK POINTS RESULT REMARKS

1. Career

* Steering Operability, Play

* Wheels Tire pressure, Abrasion
* Brake / Pedal / Lever Operating check, Play
* Clutch / Brake Operating check
* Signal / Horn Reverse alarm, Turn signal
* Lighting Head, Tail, Brake light
* Out rigger / Timber pads Damage, Missing

2. Lift operating devices

* Levers Operating check, Play
* Brakes Operating check, Play
* Emergency stopper Operating check
* Telescope cylinder Operating check
* Scissor boom Operating check
* Man basket Door latch, Hand rails
* Basket balance / Moving devices Level, Smooth operation

3. Safety devices
* Warning sign Indication
* Safe guard for moving part Breakage, Missing

C:ayajid\form\cevtminsp.xls Printed : 02/08/2024 at 04:07:49 Page : 21 of 36

 Comments :

Inspected by,

( __________________ ) ( __________________ )
ME2 - Safety Officer Mech.Spv./Site Eng.

C:ayajid\form\cevtminsp.xls Printed : 02/08/2024 at 04:07:49 Page : 22 of 36

 Cirebon 2, 1x1000MW Coal Fired Power Plant Project

FORK LIFT INSPECTION

Reference : Doc. No. Form - 005 Rev. 0

Date of Inspection Re-inspection

Equipment data : Operator / Driver data :

Registration Number Name

Manufacture Sex (male/female)

Serial Number Age

Police Number (if any) License / SIO

Capacity Expired

Certificate Exp.

Subject : Fork Lift ……………

Result column : Yes/good, Acceptable X Not/Bad, Not To Use NA Not Applicable

Copy of Driving license, Operator certificate and Equipment certificate must be attached in this form

NO CHECK ITEM CHECK POINTS RESULT REMARKS

1. Power unit
* Engine Starting, sound, Vibration
* Engine oil . Filter / Piping Volume, Smudge, Leakage
* Fuel (Tank / Pump / Hose / Filter) Leakage, Breakage, Smudge
* Radiator / Pump / Fan belt Water volume, Leakage, Damage
* Transmission / Torque conventer Oil volume, Leakage, Smudge
* Muffler / Flame arrestor Exhaust color, Sound, Missing

2. Electric system
* Battery Liquid volume, Aging, Terminal
* Starter motor / Dynamo Function, Breakage
* Wiring Damage, Connection

3. Hydraulic / Pneumatic devices

* Oil tank / Filter Damage, Oil volume, Smudge
* Oil pump / Motor Sound, leakage, Overheat
* Control valve / Brake valve Function, Leakage
* Hose / Piping / Fitting Damage, Leakage, Connection

4. Operation
* Steering Operating check, Breakage
* Levers / Pedal Operating check, Breakage
* Clutch Operating check, Breakage
* Brakes Operating check, Breakage
* Wheels Tire pressure, Abrasion

C:/ayajid\form\cevtminsp.xls Printed : 02/08/2024 at 04:07:49 Page : 23 of 36

 NO CHECK ITEM CHECK POINTS RESULT REMARKS
5. Accessories
* Fork / Mast Damage, Tension
* Chain / Chain wheel Abrasion, Crack
* Backrest Abrasion, Damage
* Head guard Operating check, Play
* Lighting Deform, Breakage
* Indicators Deform, Breakage
* Horn / Signal Deform, Breakage
* Safe guard for moving part Color, Sound
* Pallets Leakage, Damage
* Mirrors Damage, Crack, Missing
* Wind shield (if any) Damage
* Wiper (if any) Deformation, Abrasion

6. Miscellaneous

Comments :

Inspected by,

( __________________ ) ( __________________ )
ME2 - Safety Officer Mech.Spv./Site Eng.

C:/ayajid\form\cevtminsp.xls Printed : 02/08/2024 at 04:07:49 Page : 24 of 36

 Cirebon 2, 1x1000MW Coal Fired Power Plant Project

PILE DRIVING INSPECTION

Reference : Doc. No. Form - 004 Rev. 0

Date of Inspection Re-inspection

Equipment data : Operator / Driver data :

Registration Number Name

Manufacture Sex (male/female)

Serial Number Age

Police Number (if any) License / SIO

Capacity Expired

Certificate Exp.

Subject : Pile driver Pile drawer Boring machine Earth auger ………….
Result column : Yes/good, Acceptable X Not/Bad, Not To Use NA Not Applicable

Copy of Driving license, Operator certificate and Equipment certificate must be attached in this form

NO CHECK ITEM CHECK POINTS RESULT REMARKS

1. Power unit
* Engine Starting, sound, Vibration
* Engine oil . Filter / Piping Volume, Smudge, Leakage
* Fuel tank / Pump / Filter / Piping Leakage, Breakage, Smudge
* Radiator / Pump / Fan belt Water volume, Leakage, Damage
* Air cleaner element Damage, Leakage, Smudge
* Transmission / Torque conventer Oil volume, Leakage, Smudge
* Muffler / Flame arrestor Exhaust color, Sound, Missing

2. Electric system
* Battery Liquid volume, Aging, Terminal
* Starter motor / Dynamo Function, Breakage
* Wiring Damage, Connection

3. Hydraulic / Pneumatic devices

* Hydraulic oil tank / Filter Damage, Oil volume, Smudge
* Hydraulic pump / Motor Sound, leakage, Overheat
* Hydarulic cylinder Damage, Leakage
* Compressor / Air tank Damage, Leakage
* Piping / hose / Fitting Damage, Leakage, Connection

4. Operation
* Levers / Pedal Operating check, Breakage
* Clutch (hoist, swing) Operating check, Breakage
* Brakes (hoist, swing) Operating check, Breakage

C:ayajid\form\cevtminsp.xls Printed :02/08/2024 at 04:07:49 Page : 25 of 36

 * Locks (hoist, swing) Operating check, Breakage

NO CHECK ITEM CHECK POINTS RESULT REMARKS

5. Travelling
* Caterpillar / Chains Damage, Tension
* Shoe / Rink / Pin / Bush Abrasion, Crack
* Upper / lower roller Abrasion, Damage
* Brake / Brake pedal Operating check, Play

6. Diesel hammer
* Ladder Deform, Breakage
* Cylinder Deform, Breakage
* Ram Deform, Breakage
* Exhaust / Muffler Color, Sound
* Fuel (tank / pump / hose) Leakage, Damage
* Pile cap Damage, Crack, Missing
* Cushion Damage
* Wire rope Deformation, Abrasion

7. Earth auger
* Auger screw Abrasion, Damage
* Coupling Fitting, Damage
* Motor / Motor cover Noise, Overheat, Damage

8. Safety devices / Guards

* Head guard Damage, Missing, Corrosion
* Lighting Function, Missing
* Horn / Alarm Function, Missing, Sound
* Meters (fuel, temperatur, speed) Function, Missing

9. Miscellaneous

Comments :

Inspected by,

C:ayajid\form\cevtminsp.xls Printed :02/08/2024 at 04:07:49 Page : 26 of 36

 ( __________________ ) ( __________________ )
ME2 - Safety Officer Mech.Spv./Site Eng..

C:ayajid\form\cevtminsp.xls Printed :02/08/2024 at 04:07:49 Page : 27 of 36

 Cirebon 2, 1x1000MW Coal Fired Power Plant Project

SOIL HANDLING EQUIPMENT INSPECTION

Reference : Doc. No. Form - 003 Rev. 0

Date of Inspection Re-inspection

Equipment data : Operator / Driver data :

Registration Number Name

Manufacture Sex (male/female)

Serial Number Age

Police Number (if any) License / SIO

Capacity Expired

Certificate Exp.

Subject : Bulldozer Backhoe Road roller Power shovel Drug line

Clamshell Grader Scraper Wheel loader
Result column : Yes/good, Acceptable X Not/Bad, Not To Use NA Not Applicable

Copy of Driving license, Operator certificate and Equipment certificate must be attached in this form

NO CHECK ITEM CHECK POINTS RESULT REMARKS

1. Power unit
* Engine Starting, sound, Vibration
* Engine oil . Filter / Piping Volume, Smudge, Leakage
* Fuel tank / Pump / Filter / Piping Leakage, Breakage, Smudge
* Radiator / Pump / Fan belt Water volume, Leakage, Damage
* Air cleaner element Damage, Leakage, Smudge
* Transmission / Torque conventer Oil volume, Leakage, Smudge
* Muffler / Flame arrestor Exhaust color, Sound, Missing

2. Electric system
* Battery Liquid volume, Aging, Terminal
* Starter motor / Dynamo Function, Breakage
* Wiring Damage, Connection

3. Hydraulic / Pneumatic devices

* Hydraulic oil tank / Filter Damage, Oil volume, Smudge
* Hydraulic pump / Motor Sound, leakage, Overheat
* Hydarulic cylinder Damage, Leakage
* Compressor / Air tank Damage, Leakage
* Piping / hose / Fitting Damage, Leakage, Connection

4. Operation
* Levers / Pedal Operating check, Breakage
* Clutch Operating check, Breakage
* Brakes Operating check, Breakage
* Locks (swing / bucket / arm) Operating check, Breakage
NO CHECK ITEM CHECK POINTS RESULT REMARKS

5. Travelling
* Caterpillar / Chains Damage, Tension
* Shoe / Rink / Pin / Bush Abrasion, Crack
* Upper / lower roller Abrasion, Damage
* Brake / Brake pedal Operating check, Play

6. Attachment
* Shovel / Bucket / Blade Damage, Fitting
* Wire rope / Sheaves / Chain Abrasion, Damage, Fitting

7. Safety devices / Guards

* Head guard Damage, Missing, Corrosion
* Lighting Function, Missing
* Horn / Alarm Function, Missing, Sound
* Meters (fuel, temperatur, speed) Function, Missing

8. Wheel type equipment

* Wheels Tire pressure, Abrasion
* Foot brake / Hand brake Operating check
* Handle Operability, Play, Breakage

9. Others
* Driver's seat / Seat belt Damage, Dirt, Missing
* Mirrors Missing, Breakage
* Door latches / Locks Defect, Missing

10. Miscellaneous

Comments :

Inspected by,

( __________________ ) ( __________________ )
Safety Officer Mech.Spv./Site Eng..
 Cirebon 2, 1x1000MW
Coal Fired Power Plant Project

VEHICLE INSPECTION
Reference : Doc. No. Form - 002 Rev. 0

Date of Inspection Re-inspection

Equipment data : Operator / Driver data :

Registration Number Name

Manufacture Sex (male/female)

Year Age

Type / Model License (Class)

Police Number Expired

Certificate-STNK Exp.

Subject : Dump truck Truck crane Truck Tr. mixer Trailer Light vehicle
Result column : Yes/good, Acceptable X Not/Bad, Not To Use NA Not Applicable

Copy of driving license and vehicle certificate (STNK) must be attached in this form

NO CHECK ITEM CHECK POINTS RESULT REMARKS

1 Carrier Body / Frame Damage, Deformation

2 Wheels / Spare wheel Tire pressure, Abrasion
3 Handle / Power stering Operability, Play, Breakage
4 Foot / Hand brakes Operating check, play
5 Clutch / Lever / Pedals Operating check
6 Engine Starting, Sound, Vibration
7 Battery / Wiring Liquid vol., Aging, Terminal
8 Engine oil / filter / piping Oil vol., Smudge, Leakage
9 Fuel tank / Pump / Filter / Piping Leakage, Breakage, Plugging
10 Radiator / Pump / Fan belt Water vol., Leakage, Damage
11 Transmission Oil vol., Leakage, Smudge
12 Muffler / Flame arrestor Exhaust color, Sound, Missing
13 Horn Function check
14 Reverse alarm Function check
15 Lightings
* Head light (High / Low) Breakage / Missing / Function
* Signal light (left & right side) Breakage / Missing / Function
* Inside / Door light Breakage / Missing / Function
* Brake light Breakage / Missing / Function
* Reverse light Breakage / Missing / Function
16 Indicators
* Speed indicator Function check
* Fuel indicator Function check
* Temperatur indicator Function check
* Head / Tail light indicator Function check

C:/ayajid\form\cevtminsp.xls Page : 30 of 36
rebon 2, 1x1000MW
ired Power Plant Project

CLE INSPECTION

Light vehicle

ehicle certificate (STNK) must be attached in this form

REMARKS

C:/ayajid\form\cevtminsp.xls Page : 31 of 36
 * Brake light indicator Function check

NO CHECK ITEM CHECK POINTS RESULT REMARKS

17 Wind shield Breakage, Crack

18 Wiper / Washer Function, Breakage
19 Mirrors (inside / Left & right side) Function, Breakage
20 Door latches / Locks Defect, Missing
21 Seats Breakage, Missing
22 Seat belts Missing, function

Comments :

Inspected by, Approved by,

( __________________ ) ( __________________ )

C:/ayajid\form\cevtminsp.xls Page : 32 of 36
 REMARKS

C:/ayajid\form\cevtminsp.xls Page : 33 of 36
 Cirebon 2, 1x1000MW Coal Fired Power Plant Project

CRANE/TMC INSPECTION
Reference : Doc. No. Form - 000 Rev. 0

Date of Inspection Re-inspection

Equipment data : Operator / Driver data :

Registration Number Name

Manufacture Sex (male/female)

Serial Number Age

Police Number (if any) License / SIO

Capacity Expired

Certificate Exp.

Subject : Crawler Crane RT Crane Mobile Crane Tower Crane Truck Crane
Result column : Yes/good, Acceptable Not/Bad, Not To Use Not Applicable

Copy of Driving license, Operator certificate and Equipment certificate must be attached in this form

NO CHECK ITEM CHECK POINTS RESULT REMARKS

I. CARRIER
1 Carrier Body / Frame Damage, Deformation
2 Wheels Tire pressure, Abrasion
3 Steering Operability, Play, Breakage
4 Foot / Hand brakes Operating check, play
5 Clutches / Lever / Pedals Operating check
6 Engine Starting, Sound, Vibration
7 Battery / Wiring Liquid vol., Aging, Terminal
8 Engine oil / filter / piping Oil vol., Smudge, Leakage
9 Fuel tank / Pump / Filter / Piping Leakage, Breakage, Plugging
10 Radiator / Pump / Fan belt Water vol., Leakage, Damage
11 Transmission / Torque conventer Oil vol., Leakage, Smudge
12 Muffler / Flame arrestor Exhaust color, Sound, Missing
13 Lamps Head / tail lamp
14 Signal lights Trafficator. Brake light
15 Horn / Reverse alarm Function check
16 Indicator Fuel, Speed, Temp. Meters
17 Wiper / Washer / Mirrors Function, Breakage
18 Door latches / Locks Defect, Missing
19 Seat belts Breakage, Missing
20 Out rigger
* Out rigger beam Function, Damage, Deform
* Jack & sliders Damage, missing
* Level gauge Function, Breakage
* Out rigger pad Fucntion, Damage, Deform
* Hydraulic system / hose Function, Leakage, Oil
NO CHECK ITEM CHECK POINTS RESULT REMARKS
21 Crawler
* Caterpillar / Chains Breakage, Deform, Looseness
* Upper / lower roller Breakage, Deform, Looseness
* Hydarulic system Function, Leakage, Oil
* Gear box Breakage, Deformation

II. CRANE FUNCTION

1 Safety Divices
* Over - hoist alarm Breakage, Missing, Function
* Over load alarm Breakage, Missing, Function
* Boom angle Breakage, Missing, Function
* Load indicator Breakage, Missing, Function
* Boom hoist limiting device Breakage, Missing, Function
* Swing alarm Missing, Sound
* Load / angle chart (in the cabin) Possesion, missing

2 Power Unit
* Engine / V-belt / Clutch Starting, Sound, Vibration
* Engine oil / Filter / Pipe Oil volume, Smudge, Leakage
* Fuel tank / Filter / Pump / Pipe Leakage, Breakage, Plugging
* Radiator / Water pump Water volume, Leakage, Fan belt
* Air cleaner / Hose / Filter Air pressure, Leakage, Smudge
* Transmission / Torque converter Oil volume, Smudge, Leakage
* Exhaust / Muffler / Flame arrest. Damage, Color, Sound

3 Electric System
* Battery Liquid level, Aging, Terminal
* Starter motor / Dynamo Function, Breakage
* Wiring Damage, Connection

4 Hydraulic / Pneumatic Devices

* Hydraulic oil tank / Filter Leakage, Smudge
* Hydraulic pump / Motor Sound, Leakage, Overheat
* Accumulator Leakage, Pressure
* Compressor / Air tank Damage, Leakage
* Clutch / Brake Function, Leakage
* Piping / Hose / Jopints Damage, Leakage, Connection

5 Hoist
* Clutch / Lever Operating check, Play
* Brake / Lock Operating check, Play
* Drum lock Function, Abrasion, Damage

6 Boom hoist
* Clutch / Lever / Pedal Operating check, Play
* Brake (pedal, drum, lining) Operating check, Play
* Boom lock Operating check, Damage

NO CHECK ITEM CHECK POINTS RESULT REMARKS

 * Boom cylinder Operating check, Grease
* Telescopic cylinder Operating check, Grease
* Pin Missing, Deform

7 Swing device
* Clutch / Lever / Pedal Operating check, Play
* Swing brake (drum, lining) Abrasion, Damage
* Hook roller, Swing bearing Clearance, Abrasion, Damage
* Swing lock Function, Deformation, Damage

8 Boom / Jib wires

* Wire ropes / Guy wire
- Diameter Reduction moe than 7 %
- Strand Breakage more than 7 %
- Deformation Kink, Twist, Abrasion
- Reel winding In order
* Wire clips Put in dorder, Missing
* Sheave / Bush / Sheave guard Abrasion, Damage, Bending
* Boom / Mast / Gantry / Spreader Bend, Deform, Pin, Bolt & nuts
* Back stopper Damage, Bending
* Hook block / Safety latch Damage, Missing
9 Miscellaneous

Comments :

Inspected by, Acknowledge by, Whitness by

( __________________ ) ( __________________ ) ( __________________ )

Inspector HDEC CEPR