Formulir Peminjaman

Kami yang bertanda-tangan di bawah ini menyatakan bahwa:

1. Kami meminjam dan bertanggung-jawab atas set Lego® Mindstorms® EV3 (Core Set dan
Expansion Set) dengan jumlah komponen yang terlampir.
2. Kami berjanji untuk mengganti segera apabila terjadi kerusakan pada set Lego Mindstorm di
atas. Kami menyadari bahwa apabila kami tidak bertanggung-jawab atas kerusakan tersebut,
kami memahami hal itu berarti nilai kuliah Pengantar Rekayasa & Desain kami akan dikurangi.

Nama NIM TTD(Materai) Nama NIM TTD(Materai)

Asisten :
 CORE SET

Jumlah(Awal Jumlah(Akhir
Part Image Color Name Quantity
Peminjaman) Peminjaman)

Tyre Low Wide

6035364 Black 2
Ø56 X 28

6024581 Black Cable 250 Mm 4

6024583 Black Cable 350 Mm 2

6024585 Black Cabel 500 Mm 1

Technic Angular
4112282 Black 4
Beam 4X6

4142822 Black Technic 3M Beam 2

T-Beam 3X3
4552347 Black 4
W/Hole Ø4.8

4541326 Black Left Panel 5X11 1

4543490 Black Right Panel 5X11 1

4566249 Black Right Panel 3X5 1

4566251 Black Left Panel 3X5 1

1
 CORE SET

Double Cross
4121667 Black 8
Block

Technic Cross
4140430 Black 4
Block 2X1

Beam 1X2
6006140 Black 4
W/Cross And Hole

370526 Black Cross Axle 4M 4

370626 Black Cross Axle 6M 4

370726 Black Cross Axle 8M 2

370826 Black Cross Axle 12M 2

373726 Black Cross Axle 10M 2

Angle Element, 0
4107085 Black 4
Degrees [1]

Angle Element, 90
4107767 Black 2
Degrees [6]

Angle Element,
4107783 Black 4
180 Degrees [2]

2
 CORE SET

Connector Peg W.
4121715 Black 60
Friction

4198367 Black Damper 2M 4

Upper Part For

4652236 Black 2
Turntable Z28

Double Conical
4177431 Black 2
Wheel Z12 1M

Technic Angular
4248204 Black 4
Wheel

Double Conical
4255563 Black 2
Wheel Z36

Double Conical
6093977 Black 2
Wheel Z20 1M

Lever 1X4,
4142236 Black 2
Without Notch

Technic Cross
4162857 Black 4
Block/Fork 2X2

2X1X3 Steering
4563044 Black 2
Knuckle Arm

4582792 Black Sprocket, ظ40,7 4

3
 CORE SET

Track Element,
6014648 Black 54
5X1,5

Tyre For Wedge-

6028041 Black 4
Belt Wheel

Brick
4514554 3M Connector Peg 6
Yellow

Brick Connector
4666579 8
Yellow Peg/Cross Axle

Brick Conical Wheel

4565452 2
Yellow Z12

Bright
4509376 Technic 3M Beam 4
Blue

Bright Conn.Bush
4206482 20
Blue W.Fric./Crossale

Bright Connector Peg W.

4514553 30
Blue Friction 3M

Technic Ang.
4141270 Bright Red 6
Beam 4X2 90 Deg

4153718 Bright Red Technic 3M Beam 4

Hto V Beam 90
6008527 Bright Red 2
Degr.

4
 CORE SET

2M Fric. Snap
4140806 Bright Red 22
W/Cross Hole

2M Cross Axle W.
4142865 Bright Red 10
Groove

Cross Axle,
4513174 Bright Red 6
Extension, 2M

Bright
4153707 Technic 3M Beam 4
Yellow

Bright
4239601 1/2 Bush 10
Yellow

Dark
6007973 Technic 3M Beam 4
Green

Dark
4210857 Stone Cross Blok 3M 8
Grey

Dark
4610380 Stone Power Joint 1
Grey

Dark
Cross Axle 8M
4499858 Stone 2
With End Stop
Grey

Dark
Cross Axle 4M
6083620 Stone 2
With End Stop
Grey

Dark
4514558 Stone Gear Wheel Z24 4
Grey

5
 CORE SET

Dark
Gear Wheel T=8,
6012451 Stone 4
M=1
Grey

Dark
Wedge-Belt
4587275 Stone 4
Wheel Ø24
Grey

Medium Rim Wide

4634091 Stone 43,2X26 W 6 2
Grey Hol.Ø 4.8

Medium
Ms, Ev3, Touch
6008472 Stone 2
Sensor
Grey

Medium
Ms-Ev3, Medium
6008577 Stone 1
Motor
Grey

Medium
Ms, Ev3, Gyro
6008916 Stone 1
Sensor
Grey

Medium
Ms, Ev3, Sensor,
6008919 Stone 1
Colour
Grey

Medium
Ms-Ev3,
6063629 Stone 1
Ultrasonic Sensor
Grey

Medium
Technic 11M
4156151 Stone 4
Beam
Grey

Medium
Technic Angular
4211624 Stone 4
Beam 3X7
Grey

Medium
4211651 Stone Technic 5M Beam 4
Grey

6
 CORE SET

Medium Technic Ang.

4211713 Stone Beam 3X5 90 2
Grey Deg.

Medium
4211866 Stone Technic 9M Beam 6
Grey

Medium
4495930 Stone Technic 7M Beam 4
Grey

Medium
Technic 13M
4522934 Stone 6
Beam
Grey

Medium
Technic 11M
4611705 Stone 4
Beam
Grey

Medium
6102449 Stone Technic 9M Beam 6
Grey

Medium
4211775 Stone Cross Block 90° 8
Grey

Medium
Beam 3 M. W/4
4225033 Stone 6
Snaps
Grey

Medium Angular Beam

4296059 Stone 90Degr. W.4 4
Grey Snaps

Medium
4538007 Stone Cross Block 3X2 6
Grey

Medium
Beam Frame 5X7
4539880 Stone 3
Ø 4.85
Grey

7
 CORE SET

Medium
Beam R. Frame
4540797 Stone 1
5X11 Ø4.85
Grey

Medium
Double Bush 3M
4560175 Stone 4
Ø4.9
Grey

Medium
Bush For Cross
4211622 Stone 10
Axle
Grey

Medium
4211639 Stone Cross Axle 5M 6
Grey

Medium
4211805 Stone Cross Axle 7M 5
Grey

Medium
4211807 Stone Connector Peg 10
Grey

Medium
4211815 Stone Cross Axle 3M 14
Grey

Medium
3-Branch Cross
4502595 Stone 2
Axle W/Cross H.
Grey

Medium
Tube W/Double
4526985 Stone 4
Ø4.85
Grey

Medium
4535768 Stone Cross Axle 9M 2
Grey

Medium
Lower Part For
4652235 Stone 2
Turntable Z28
Grey

8
 CORE SET

Medium
4211510 Stone Worm 2
Grey

Medium
4285634 Stone Gear Wheel 40T 2
Grey

Medium
4640536 Stone Gear Wheel Z16 4
Grey

Medium
6009019 Stone Triangel 4
Grey

Not
6079570 Steel Ball 1
specified

Sand Crossaxle 3M
6031821 2
Yellow With Knob

6009996 White Ms-Ev3, P-Brick 1

Double Angular
4495412 White 4
Beam 3X7 45°

Technic Angular
4509912 White 6
Beam 4X4

Technic 15M
4542578 White 6
Beam

Technic Ang.
4585040 White Beam 3X5 90 4
Deg.

9
 CORE SET

4173941 White Bion. Eye 4

10
 EXPANSION SET

Jumlah(Awal Jumlah(Akhir
Part Image Color Name Quantity
Peminjaman) Peminjaman)

Tyre Low Wide

6035364 Black 2
Ø56 X 28

Tyre Low Wide

6062225 Black 4
Ø68,8 X 36

403226 Black Plate 2X2 Round 4

Slide Shoe Round

4278359 Black 2
2X2

Tyre Normal Wide

4184286 Black 2
Ø43,2 X 22

Tyre Low Wide

4639695 Black 2
Ø24 X 14

Technic Angular
4112282 Black 2
Beam 4X6

T-Beam 3X3
4552347 Black 2
W/Hole Ø4.8

4541325 Black Right Panel 3X7 2

4541924 Black Left Panel 3X7 2

4558731 Black Right Panel 3X11 1

1
 EXPANSION SET

4558740 Black Right Panel 5X7 1

4558774 Black Left Panel 3X11 1

4558775 Black Left Panel 5X7 1

4566249 Black Right Panel 3X5 1

4566251 Black Left Panel 3X5 1

Bowed Panel
6031916 Black 3X11X2 Ø4,85 4
(X19)

Double Cross
4121667 Black 4
Block

Beam 1X2
6006140 Black 6
W/Cross And Hole

370526 Black Cross Axle 4M 5

370626 Black Cross Axle 6M 1

370726 Black Cross Axle 8M 1

2
 EXPANSION SET

370826 Black Cross Axle 12M 1

373726 Black Cross Axle 10M 1

Catch W. Cross
4107081 Black 22
Hole

Angle Element,
4107082 Black 4
157,5 Degr. [3]

Angle Element,
4107084 Black 3
112,5 Degr. [5]

Angle Element, 0
4107085 Black 6
Degrees [1]

Angle Element, 90
4107767 Black 2
Degrees [6]

Angle Element,
4107783 Black 5
180 Degrees [2]

4119589 Black Module Bush 4

Connector Peg W.
4121715 Black 170
Friction

Ball With Friction

4184169 Black 8
Snap

3
 EXPANSION SET

4624645 Black Turntable Ø4.85 1

Double Conical
4177431 Black 2
Wheel Z12 1M

4540906 Black Rack 13 M 2

Double Conical
6093977 Black 1
Wheel Z20 1M

4164133 Black Technic Lever 2M 2

6030286 Black Lever 5M 4

Beam 3M Ø4.85
4558692 Black 1
W. Fork

2X1X3 Steering
4563044 Black 1
Knuckle Arm

4582792 Black Sprocket, ظ40,7 2

Track Element,
6014648 Black 5
5X1,5

Cross Axle,
Brick
4207456 Extension M/3 1
Yellow
Ribs

4
 EXPANSION SET

Brick
4514554 3M Connector Peg 14
Yellow

Brick Connector
4666579 6
Yellow Peg/Cross Axle

Brick Krydsaksel M/Stop

4666999 2
Yellow 4M

Brick 1 1/2 M
6013938 6
Yellow Connecting Bush

Brick
4514557 Bevel Gear Z20 1
Yellow

Brick Conical Wheel

4565452 3
Yellow Z12

Brick
6031962 Bevel Gear Z20 1
Yellow

Bright
70904 V-Belt Ø26, Blue 2
Blue

Bright
4544147 V-Belt Ø26, Blue 2
Blue

Bright Conn.Bush
4206482 57
Blue W.Fric./Crossale

Bright Connector Peg W.

4514553 33
Blue Friction 3M

5
 EXPANSION SET

V-Belt Ø24 / Clear

4100396 Bright Red 2
Red

4544143 Bright Red V-Belt Ø 24, Red 2

Technic Ang.
4141270 Bright Red 4
Beam 4X2 90 Deg

4153718 Bright Red Technic 3M Beam 2

Right Panel 2X5

6022750 Bright Red 2
(N0 21)

Left Panel 2X5 (Nr

6022752 Bright Red 2
22)

2M Cross Axle W.
4142865 Bright Red 22
Groove

Technic Change-
4270473 Bright Red 1
Over Catch

Cross Axle,
4513174 Bright Red 4
Extension, 2M

Technic Change-
6099696 Bright Red 1
Over Catch

4185661 Bright Red Bion. Eye 2

6
 EXPANSION SET

4278957 Bright Red Driving Ring 1

Rubber
6036424 Bright Red Attachment For 28
Track Element

Bright V-Belt Ø33,

70905 2
Yellow Yellow

Bright V-Belt Ø33,

4544151 2
Yellow Yellow

Bright
4239601 1/2 Bush 16
Yellow

3 Branch
Dark
6005755 Crosshole W. 5
Brown
Hole

Dark
4210857 Stone Cross Blok 3M 4
Grey

Dark
4610380 Stone Power Joint 1
Grey

Dark
4210665 Stone Catch 2
Grey

Dark
Cross Axle 8M
4499858 Stone 6
With End Stop
Grey

Dark
Cross Axle 5,5
4508553 Stone 4
With Stop 1M.
Grey

7
 EXPANSION SET

Dark
Beam 1M W. 2
6005331 Stone 2
Cross Axles 90°
Grey

Dark
Cross Axle 4M
6083620 Stone 8
With End Stop
Grey

Dark
4211026 Stone Track Rod 6M, 2
Grey

Dark
Cardan Cup With
4610374 Stone 2
Cross Axle 2M
Grey

Dark
4629920 Stone Track Rod 6M, 2
Grey

Dark
Gear Wheel Z16-
4237267 Stone 2
Ø4.9
Grey

Dark
4514558 Stone Gear Wheel Z24 3
Grey

Dark
Differentiale 3M Z
4525184 Stone 1
28
Grey

Dark
Gear Wheel T=8,
6012451 Stone 2
M=1
Grey

Dark
4210759 Stone Comb Wheel 2
Grey

Dark
4610378 Stone 3 Snap Gearblok 2
Grey

8
 EXPANSION SET

Medium Rim Wide

4634091 Stone 43,2X26 W 6 2
Grey Hol.Ø 4.8

Medium
6045310 Stone Rim Ø 56 X 34 4
Grey

Medium
Rim Wide
4297210 Stone 3
W.Cross 30/20
Grey

Medium
Rim Wide 18/14
4490127 Stone 5
W. Cross Ø4.8
Grey

Medium Rim Narrow

6044729 Stone Ø18X7 W Hole 1
Grey Ø4.8

Medium
Technic 11M
4156151 Stone 6
Beam
Grey

Medium
Technic Ang.
4211610 Stone 8
Beam 4X2 90 Deg
Grey

Medium
4211651 Stone Technic 5M Beam 5
Grey

Medium
4211655 Stone Technic 3M Beam 10
Grey

Medium Technic Ang.

4211713 Stone Beam 3X5 90 6
Grey Deg.

Medium
4211862 Stone Technic 2M Beam 3
Grey

9
 EXPANSION SET

Medium
4211866 Stone Technic 9M Beam 7
Grey

Medium
Double Angular
4234240 Stone 4
Beam 3X7 45°
Grey

Medium
4495930 Stone Technic 7M Beam 16
Grey

Medium
Technic 11M
4611705 Stone 6
Beam
Grey

Medium
6102449 Stone Technic 9M Beam 7
Grey

Medium
Technic
4211714 Stone 4
Crossblock 2X3
Grey

Medium
4211775 Stone Cross Block 90° 4
Grey

Medium
Beam 3 M. W/4
4225033 Stone 10
Snaps
Grey

Medium Angular Beam

4296059 Stone 90Degr. W.4 4
Grey Snaps

Medium
4538007 Stone Cross Block 3X2 2
Grey

Medium
Beam Frame 5X7
4539880 Stone 9
Ø 4.85
Grey

10
 EXPANSION SET

Medium
Beam R. Frame
4540797 Stone 6
5X11 Ø4.85
Grey

Medium
Double Bush 3M
4560175 Stone 2
Ø4.9
Grey

Medium
Power Joint
4610379 Stone 1
Ballpart
Grey

Medium
4652234 Stone Krydsblok 2X4 3
Grey

Medium
4211375 Stone Ball W. Cross Axle 2
Grey

Medium
Bush For Cross
4211622 Stone 45
Axle
Grey

Medium
4211639 Stone Cross Axle 5M 8
Grey

Medium
4211758 Stone Hub Ø11,2 X 7,84 7
Grey

Medium
4211805 Stone Cross Axle 7M 2
Grey

Medium
4211815 Stone Cross Axle 3M 12
Grey

Medium
4525904 Stone Propeller Shaft 2
Grey

11
 EXPANSION SET

Medium
Tube W/Double
4526985 Stone 2
Ø4.85
Grey

Medium
4535768 Stone Cross Axle 9M 5
Grey

Medium
4268659 Stone Lt Cardan Ball 2
Grey

Medium
6122217 Stone Lt Cardan Ball 2
Grey

Medium
4211510 Stone Worm 1
Grey

Medium
4285634 Stone Gear Wheel 40T 2
Grey

Medium
Cone Wheel Z20
4558690 Stone 2
Ø4.85
Grey

Medium
4211566 Stone Technic Lever 3M 10
Grey

Medium
4211741 Stone Technic Lever 2M 1
Grey

Medium
6009019 Stone Triangel 5
Grey

Medium
Gear Block 3½
4610377 Stone 2
6½X3
Grey

12
 EXPANSION SET

Sand Crossaxle 3M
6031821 16
Yellow With Knob

Silver Flex Hose 19M

6044636 2
Metallic W/3. 18 Stick

Transpare
6027626 Half Spike Ball 2
nt Blue

Transpare
nt
611649 Brick 2X2 Round Ii 2
Fluoresce
nt Green
Transpare
4178398 nt Light Brick 2X2 Round Ii 2
Blue

Transpare
4654432 nt Light Weapon Barrel 2
Blue

Transpare
Corrugated Pipe
4631648 nt Light 4
152Mm
Blue

Transpare Nose Cone Small

4544720 4
nt Red 1X1 - Tr

Transpare Flat Tile 1X1,

4646864 6
nt Red Round

70902 White V-Belt Ø15, White 2

4544140 White V-Belt Ø15, White 2

13
 EXPANSION SET

4208160 White Technic 3M Beam 1

Double Angular
4495412 White 2
Beam 3X7 45°

Technic 15M
4542578 White 13
Beam

4173941 White Bion. Eye 1

14