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FORM / FORMULIR |
No. Dokumen |
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GSI4-OPR-002N |
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| Revisi |
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0 |
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| P2H |
Tanggal Efektif |
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18-Sep-24 |
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| KENDARAAN LV |
Halaman |
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1 |
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NAMA DRIVER |
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Rahmatullah |
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SHIFT |
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Siang |
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DEPARTEMEN |
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HSEQT |
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NO. ALAT |
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LV.007 |
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TANGGAL |
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2026-09-24 |
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KM AKHIR |
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124387 |
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KETERANGAN : |
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1. |
Pada kolom
"Kondisi" beri tanda ( ✔ ) sesuai dengan kondisi kendaraan pada
saat pemeriksaan |
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2. |
Tuliskan
di kolom catatan, apabila ada informasi tambahan mengenai kerusakan /
ketidaksesuaian yang ditemukan |
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3. |
Bila
ditemukan dari pemeriksaan ada temuan Rusak dan perlu dilengkapi segera
laporkan ke Pengawas/Mekanik |
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| NO |
ITEM YANG
HARUS DIPERIKSA |
KODE |
KONDISI |
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ITEM YANG
HARUS DIPERIKSA |
KODE |
KONDISI |
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| BAIK |
Rusak / Tidak
Sesuai |
Tidak Ada |
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BAIK |
Rusak / Tidak
Sesuai |
Tidak Ada |
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| PEMERIKSAAN
KELILING UNIT / DILUAR KABIN |
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PEMERIKSAAN KELILING UNIT / DILUAR KABIN |
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| 1 |
Level Oli Transmisi |
AA |
✔ |
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16 |
Kemudi (Steering) |
AA |
✔ |
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| 2 |
Air Radiator |
AA |
✔ |
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17 |
Rem Tangan |
AA |
✔ |
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| 3 |
Level Oli Kemudi |
AA |
✔ |
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18 |
Rem Kaki |
AA |
✔ |
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| 4 |
Level Oli Engine |
AA |
✔ |
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19 |
Klakson |
AA |
✔ |
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| 5 |
Level Oli Rem |
AA |
✔ |
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20 |
Panel Indikator/Gauge |
AA |
✔ |
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| 6 |
Level Oli Perseneling |
AA |
✔ |
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21 |
4WD Double Gardan |
AA |
✔ |
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| 7 |
Body Unit |
AA |
✔ |
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22 |
Wipers |
AA |
✔ |
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| 8 |
Ban, Baut Roda |
AA |
✔ |
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23 |
Radio Rig |
AA |
✔ |
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| 9 |
Kaca Spion |
AA |
✔ |
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24 |
Seat Belt |
AA |
✔ |
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| 10 |
Alarm Mundur |
AA |
✔ |
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25 |
Tempat Duduk |
A |
✔ |
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| 11 |
Lampu Rem & Sein |
AA |
✔ |
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26 |
Dongkrak |
A |
✔ |
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| 12 |
Lampu Depan |
AA |
✔ |
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27 |
Ganjal Roda |
A |
✔ |
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| 13 |
Lampu Rotary |
AA |
✔ |
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28 |
Kebersihan Kabin |
A |
✔ |
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| 14 |
Air Wiper dan Air Aki |
A |
✔ |
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29 |
Kunci Baut Roda |
A |
✔ |
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| 15 |
Tiang Bendera |
A |
✔ |
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30 |
APAR |
A |
✔ |
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| PENTING : |
1. |
Kode Bahaya A: |
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Unit harus diperbaiki
sebelum di operasikan |
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2. |
Kode Bahaya AA: |
Berhenti
dan SEGERA Laporkan Keatasan, putuskan lanjutkan atau perbaiki segera |
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3. |
Mengoperasikan alat
dengan kerusakan AA akan dikenakan sanksi sesuai Peraturan Perusahaan |
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| CATATAN : Tuliskan bila ada temuan dan kelainan selain item
diatas |
DIISI OLEH, |
DIPERIKSA OLEH, |
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| Rahmatullah |
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| TTD DRIVER |
TTD PENGAWAS |
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