PT.

SUPERSONIC CHEMICAL INDUSTRY

FORM INSPEKSI KENDARAAN - INSPECTION FOR VEHICLE

No. Kendaraan / Vehicle Number : Hari / tanggal / Day / date :

Dept. / Pengguna / Dept. / User : Lokasi / Location :

Bagian yang Diperiksa Bagus Rusak Keterangan
No.
Inspected items Good Broken Remark

Kondisi Keselamatan Utama / Primary Safety Condition

1 Sabuk pengaman ( pengemudi & penumpang ) Safety belts ( driver & passenger )
2 Lampu depan, belakang, & tanda berbelok Head / rear lights & turn signals
3 Rem utama dan lampu rem Main brake and lights
4 Rem & lampu parkir Parking brake & lamps
5 Klakson & alarm mundur Horn & reverse alarm
6 Spion, kaca depan & penghapus air Side mirrors, windscreen & wipers
7 Pengukur jarak & kecepatan Odometer & speedometer
8 Pengunci pintu Door locks
9 Kondisi ban Tire conditions
10 Tekanan ban & kondisi roda (baut-baut ) Tire pressure & wheel conditions ( bolt )

Kondisi Keselamatan Tambahan / Additional Safety Condition

11 Tabung pemadam kebakaran Fire extinguisher cylinder
12 Kotak P3K First aid kit
13 Dongkrak & peralatan standard Jack & basic toolkit
14 Segitiga pengaman Safety triangle
15 Sabuk pengaman penumpang baris berikutnya Safety belts for other rows passenger
16 STNK dan buku Kir ( bila diperlukan ) Vehicle documents
17 Kaca samping Door & side glasse s
18 Ban cadangan Spare tire

Kondisi Mekanis dan Kebersihan Mechanical Conditions and Cleanliness

19 kargo cargo
20 ruang kargo kedap air waterproof cargo space
21 Penutup terpal Tarpaulin cover
22 pompa hi blow hi blow pump
23 Selang Pompa Pump Hose
24 Kebersihan ruang kargo Cleanliness of cargo space
25 terpal untuk alas tarpaulin for the base

Catatan / Note : Segera melapor ke Supervisor jika ada bagian-bagian yang tidak berfungsi dengan baik atau rusak
Report to Supervisor immediately if some items / parts are not in good condition or broken.

Pengemudi / Driver Supervisor

Nama / Name Nama / Name

Dept. Dept.

Tanda tangan / Signature Tanda tangan/Signature

Catatan kepada mekanik / Note to mechanic