DUMP TRUCK INSPECTION

CHECKLIST
FORM

Doc. No. : HSE-F-OA-039 Rev. : A

Date : 4 Januari 2021 Page : 1 of 2

   
PEMILIK/ TAHUN PEMBUATAN/
   
COMPANY YEARS MANUFACTURE
   
 
   
MODEL
  PABRIK / BRAND  
     
NO. POLISI /    
POLICY   TANGGAL DIPERIKSA /  
NUMBER   DATE INSPECTION  
KONDISI / KETERANGAN /
CONDITION ASPEK YANG DI PERIKSA /ASPECT TO BE CHECK REMARKS
 
UMUM / Kondisi fisik secara umum / Condition physic in general   
Rangka & Chasis (Karat / Rusak) / Chasis (Corotion /  
GENERAL Broken)
  Roda / Ban kanan – kiri / Condition Tier (Right / Left) 
Mesin (kotor, ada oli, dll) / Does Condition Machine
  Dirty   
Knalpot (Diberi Peredam / Diberi Pembalut ?) / Does
  arrestor has cap  
  Klaxon / Does Horn working properly   
 
  Cairan hidraulic (Bocor ?) / Does Hydrolic Leak ?   
  Rem / Does Brake work properly 
  Tutup Tangki BBM / Does cap gasoline appear 
Pintu (bisa menutup? ada pegangan ?) / Does door can  
KABIN / be close and have handle ?  
CABIN Lampu penerangan / Does dashboard lamp work 
 
Jendela dan Kaca Jendela (ada yang pecah ?) / Does  
  window and window glass in good condition?
  Kotak P3K / Does first aid box inside? 
Penghapus air hujan (wiper) / Does water in wiper tank  
  full? 
 
Alat Pemadam Api Ringan / Does Fire Extinguisher  
  inside ? 
 
Lampu Besar / Does infront lamp work
LAMPU /
LAMP Lampu Jalan
Lampu Kecil Depan
 
Lampu Belakang / Does back lamp work  
   
Controlled Copy, Do Not Duplicate For Internal Use Only
 DUMP TRUCK INSPECTION
CHECKLIST
FORM

Doc. No. : HSE-F-OA-039 Rev. : A

Date : 4 Januari 2021 Page : 2 of 2

Lampu Rem / Does Brake Lamp Work   

   
Lampu Sign Kanan / Does Right Sign Lamp Work  
   
Lampu Sign Kiri / Does Left Sign Lamp Work   
     
Lampu Mundur / Does Reverse Lamp Work   
     
Hidraulic (baik ?) / Does hydraulic leak   
BAK    
 
  Karat / Rusak / Does it corotion / broken  

Pintu Belakang (Baik / Macet) / Does back door in good

condition    
     

Rekomendasi:

HSE Inspector HSE Mgr./ Chief HSE

Controlled Copy, Do Not Duplicate For Internal Use Only