PRE-MOBILIZATION / QUARTERLY

Crane Carry-In Inspection

Form - 001
Type of Crane : CARRY-IN CERTIFICATE

Equipment No. : Permit No. :

Capacity : Date :

Manufacturer :
Approved by :
Company User :

Certificate Number :
Reviewed by :
Month of Inspection :
This form must be completed by the crane operator and company user before entering the crane to be operated in the site project
area, and at any time of setting location. All crane condition must meet to the safety regulation and IKPT SHE Management Plan
Result column: (  ) Yes/Good, Acceptable, (X) Not/Bad, Not to use, (NA) Not applicable
No Check Item Result Remarks
1 Manufacturer's operating and Maintenance Manuals
2 Turntable/Crane Body (Upper Works)
- Assure Level/Stability
- Wear/Gear/Teeth/Rollers
- Cracks
- Bolts/Pins - Assure Securely Attached
3 Engine Housing
- Cleanliness/No Rags/Trash
- Gear/Machinery Guards
- Clear Access/Walkways
- Brakes/Clutch Adjustments
- Hand Signal Illustration
- Swing Break
4 Swing Clearance Protection
5 Tire condition
6 Track Crawler System
- Lubrication
- Connection Bolts
- Drive Chain (slack & wear)
7 Braking Systems
8 Electrical system
- High-Voltage Warning Sign
- Lighting Device
- Wiring system
9 Safety Device
- Anti-Two Block Devices
- Boom Backstop Devices
- Swing Radius Warning Devices
10 Boom Section
- Main Boom, Jib Boom, Boom Extension
- Boom Stop
- Jib Boom Stops
- Boom Angle Indicator
- Boom Hoist Disconnect,
- Automatic Boom Hoist Shutoff
11 Leveling Indicating Device
12 Load Indicator
- Load indicator digital/analog
- Load rating Chart

13 Sheaves
 PRE-MOBILIZATION / QUARTERLY

- Ensure hoist line and sheave size match

- Worn
- Lubrication/Move freely
14 Main Hoist and Auxiliary Drums System
- Proper Size and Spoiling of Hoist lines
- Drum Sides/Shields for Cracks
- Dogs/Pawls/Locking Devices
- Drum Rotation vs. Control Motion
- Clutch and Brakes
15 Load Hooks and Hook Blocks
- Sheaves Function Smoothly
- Hook Rotates Freely/Lubricated
- Proper Becket
- Properly Reeve
- Safety latch
16 Hydraulic Hoses Fittings and Tubing
17 Outriggers
- Lubrication
- Structural Condition
- Pressure hoses/connections
18 Wire Rope
- Overall Condition
- End Connections
- Lubrication
- Clips
19 Cab
- Glass/Visibility
- Instruments and Controls
- Functioning Horn (warning signal)
- Fire Extinguisher
- Appropriate Load Charts and Warning Signs
- Proper and Adequate Access (steps/walkway)
20 Counterweight
- Proper Size
- Attachment Connection/Bolts
21 Load test
INSPECTOR REPORT

Corrective Action Required

Inspection Status:  OK  Not OK  Order for Repair

Subcontractor
Inspected by Date: Name : Signature :
Position :
Approved by Date : Name : Signature :
Position :
Contractor
Inspector Date : Name : Signature :
Position :
Reviewer Date : Name : Signature :
Position :
Name :
SHE Manager Date :
Position : Signature :
Form - 002
Crane Inspection
 PRE-MOBILIZATION / QUARTERLY

Type of Crane : CARRY-IN CERTIFICATE

Equipment No. : Permit No. :

Capacity : Date :
Manufacturer :
Approved by :
Company User :
Certificate Number :
Reviewed by :
Month of Inspection :
This form must be completed by the crane operator and company user before entering the crane to be operated in the
site project area, and at any time of setting location. All crane condition must meet to the safety regulation and IKPT
SHE Management Plan

Result column: (  ) Yes/Good, Acceptable, ( X ) Not/Bad, Not to use, ( NA ) Not applicable

No Check Item Result Remarks

1 Operator has a valid License

2 Equipment has valid certificate
3 Hydraulic system in good condition
4 Crawler/Tire condition
5 Boom / Fly Jeep
6 Block Hook
7 Hook Completed with Safety latch
8 All electrical system are in good
9 Brake system
10 Operations Handle
11 Back Mirror
12 Lighting Device
13 Alarm System
14 SWL Chart Provided/Displayed
15 Wire sling is in good condition?
16 Rigger man provided / qualified?
17 Fork horn in good condition?
18 Lubrication system
19 Oil leaking
20 Fuel Reservoir
21 Each Side of windows glasses
22 Leveling indicator devices
23 Auxiliary Drum
24 Fire Extinguisher
 PRE-MOBILIZATION / QUARTERLY

INSPECTOR REPORT
Corrective Action Required

Inspection Status:  OK

 Not OK

 Order for Repair

Subcontractor
Inspected by Date : Name : Signature :
Position :
Approved by Date : Name : Signature :
Position :
Contractor
Inspector Date : Name : Signature :
Position :
Reviewer Date : Name : Signature :
Position :
SHE Manager Date : Name : Signature :
Position :

Form - 003
 PRE-MOBILIZATION / QUARTERLY

Pile Driving Machine Inspection

□ Pile Driver □ Pile Drawer □ Boring Machine □ Earth Auger

Type of Crane : CARRY-IN CERTIFICATE

Equipment No. : Permit No. :

Capacity : Date :
Manufacturer :
Approved by :
Company User :
Certificate Number :
Reviewed by :
Month of Inspection :
This form must be completed by the crane operator and company user before entering the crane to be operated in the
site project area, and at any time of setting location. All crane condition must meet to the safety regulation and IKPT
SHE Management Plan

Result column: (  ) Yes/Good, Acceptable, ( X ) Not/Bad, Not to use, ( NA ) Not applicable

No Check Item Result Remarks

1 Operator has a valid License

2 Equipment has valid certificate
3 Hydraulic system in good condition
4 Crawler/Tire condition
5 Boom / Fly Jeep
6 Block Hook
7 Hook Completed with Safety latch
8 All electrical system are in good
9 Brake system
10 Operations Handle
11 Back Mirror
12 Lighting Device
13 Alarm System
14 SWL Chart Provided/Displayed
15 Wire sling is in good condition ?
16 Rigger man provided / qualified ?
17 Fork horn in good condition ?
18 Lubrication system
19 Oil leaking
20 Fuel Reservoir
21 Each Side of windows glasses
22 Leveling indicator devices
23 Auxiliary Drum
24 Fire Extinguisher
 PRE-MOBILIZATION / QUARTERLY

INSPECTOR REPORT
Corrective Action Required

Inspection Status:  OK

 Not OK

 Order for Repair

Subcontractor
Inspected by Date : Name : Signature :
Position :
Approved by Date : Name : Signature :
Position :
Contractor
Inspector Date : Name : Signature :
Position :
Reviewer Date : Name : Signature :
Position :
SHE Manager Date : Name : Signature :
Position :
 PRE-MOBILIZATION / QUARTERLY

Soil Handling Equipment

□ Bulldozer □ Backhoe □ Road Roller □ Power Shovel □ Drag-line

□ Clamshell □ Grader □ Scraper □ Wheel Loader
Type of Equipment : CARRY-IN CERTIFICATE

Equipment No. : Permit No. :

Manufacturer : Date :

Company User :
Approved by :
Certificate Number :

Month of Inspection : Reviewed by :

This form must be completed by the operator and company user before entering the equipment to be operated in the site project
area, and at any time of setting location. All equipment condition must meet to the safety regulation and IKPT SHE Management
Plan

Result column: (  ) Yes/Good, Acceptable, ( X ) Not/Bad, Not to use, ( NA ) Not applicable

No Check Item Result Remarks

1 Operator has a valid License

2 Equipment has valid certificate
3 Hydraulic system in good condition
4 Traveling system in good condition
5 All electrical system are in good
6 Brake system
7 Operations Handle
8 Back Mirror
9 Lighting Device
10 Alarm System
11 Safety device
12 Rigger man provided / qualified
13 Fork horn in good condition
14 Lubrication system
15 Safe Guards for moving parts
16 Oil leaking
17 Fuel Reservoir
18 Fire Extinguisher
19 Others
INSPECTOR REPORT
Corrective Action Required

Inspection Status:  OK  Not OK  Order for Repair

Subcontractor
Inspected by Date : Name : Signature :
Position :
Approved by Date : Name : Signature :
Position :
Contractor
Inspector Date : Name : Signature :
Position :
Reviewer Date : Name : Signature :
 PRE-MOBILIZATION / QUARTERLY

Position :
SHE Manager Date : Name : Signature :
Position :

Form - 005

Fire Extinguishers Inspection

EXTINGUISHERS CONDITIONS
NO OK TYPE NUMBER PRESSURE GAUGE NOZLE POWDER HANDLE COMMENT
( CARTUDGE )

Subcontractor
Inspected by Date : Name : Signature :
Position :
Approved by Date : Name : Signature :
Position :
Contractor
Approved by Date : Name : Signature :
Position :
 PRE-MOBILIZATION / QUARTERLY

Form - 006

Forklift Inspection

Type of Equipment : CARRY-IN CERTIFICATE

Equipment No. : Permit No. :

Capacity : Date :
Manufacturer :
Approved by :
Company User :
Certificate Number :
Reviewed by :
Month of Inspection :
This form must be completed by the operator and company user before entering the equipment to be operated in the
site project area, and at any time of setting location. All equipment condition must meet to the safety regulation and
IKPT SHE Management Plan

Result column: (  ) Yes/Good, Acceptable, ( X ) Not/Bad, Not to use, ( NA ) Not applicable

No Check Item Result Remarks

1 Operator has a valid License

2 Equipment has valid certificate
3 Hydraulic system in good condition
4 Traveling system in good condition
5 All electrical system are in good
6 Brake system
7 Operations Handle
8 Back Mirror
9 Lighting Device
10 Alarm System
11 Safety device
12 Fork horn in good condition
13 Lubrication system
14 Oil leaking
15 Fuel Reservoir
16 Safe Guards for moving parts
17 Fire Extinguisher
18

INSPECTOR REPORT
Corrective Action Required

Inspection Status:  OK  Not OK  Order for Repair

Subcontractor
 PRE-MOBILIZATION / QUARTERLY

Inspected by Date : Name : Signature :

Position :
Approved by Date : Name : Signature :
Position :
Contractor
Inspector Date : Name : Signature :
Position :
Reviewer Date : Name : Signature :
Position :
SHE Manager Date : Name : Signature :
Position :
 PRE-MOBILIZATION / QUARTERLY

Form - 007
Electrical Equipment / Tool Inspection

□ Saw □ Planer □ Bender □ Cutter □ Grinder □ Blower □

Pump
Type of Equipment : CARRY-IN CERTIFICATE

Equipment No. : Permit No. :

Company User : Approved by :
Month of Inspection : Reviewed by :
This form must be completed by the operator and company user before entering the equipment to be operated in the
site project area, and at any time of setting location. All equipment condition must meet to the safety regulation and
IKPT SHE Management Plan

Result column: (  ) Yes/Good, Acceptable, ( X ) Not/Bad, Not to use, ( NA ) Not applicable

No Check Item Result Remarks

1 Cable/Connector
2 Earth for Movable Equip.
3 Frame (body) Earth
4 Installation/Fixing
5 Abrasive Disk/Blade
6 Hand Switch
7 Pilot Lamp
8 Operations Handle
9 Safe Guards for moving parts

INSPECTOR REPORT
Corrective Action Required :

Inspection Status:  OK  Not OK  Order for Repair

Subcontractor
Inspected by Date : Name : Signature :
Position :
Approved by Date : Name : Signature :
Position :
Contractor
Approved by Date : Name : Signature :
Position :
 PRE-MOBILIZATION / QUARTERLY

Form - 008
Electrical Distribution Board
Type of Equipment : CARRY-IN CERTIFICATE

Equipment No. : Permit No.

Company User : Approved by :
Month of Inspection : Reviewed by :
This form must be completed by the operator and company user before entering the equipment to be operated in the
site project area, and at any time of setting location. All equipment condition must meet to the safety regulation and
IKPT SHE Management Plan

Result column: (  ) Yes/Good, Acceptable, ( X ) Not/Bad, Not to use, ( NA ) Not applicable

No Check Item Result Remarks
1 Appearance/Structure
2 Earth Leakage Circuit Breaker
3 Frame (Body) Earth
4 Switches/Switch covers
5 Socket/Outlet
6 Light for night, dim location
7 Pilot Lamp
8 Cable Termination
9 Installation
10 User’s Tag for Each Circuit
11 Doors Lockable/Breakage
12 Fire Extinguisher
13 Warning Sign for Elec. Shock
14 Responsible Person’s Name

INSPECTOR REPORT
Corrective Action Required :

Inspection Status:  OK  Not OK  Order for Repair

Inspected by Date : Name : Signature :

Approved by Date : Name : Signature :

Position :
Contractor
Approved by Date : Name : Signature :
Position :
 PRE-MOBILIZATION / QUARTERLY

Form - 009
Scaffolding
Type of Equipment : CARRY-IN CERTIFICATE

Equipment No. : Permit No.

Company User : Approved by :
Location :
Reviewed by :
Month of Inspection :
This form must be completed by the operator and company user before entering the equipment to be operated in the
site project area, and at any time of setting location. All equipment condition must meet to the safety regulation and
IKPT SHE Management Plan

Result column: (  ) Yes/Good, Acceptable, ( X ) Not/Bad, Not to use, ( NA ) Not applicable

No Check Item Result Remarks
1 Ladder Access (Secured and clear from material)
2 Base plate (if necessary)
3 Working floor (minimum 2 boards and
lashed)
4 Hand rail (1 meter above work floor)
5 Mid rails (0,5meter above work floor)
6 Toe boards
7 Bracing
8 Tied in
9 Strength Constructed
10 Barricade (if necessary)
11 Warning sign

INSPECTOR REPORT
Corrective Action Required

Inspection Status:  OK  Not OK  Order for Repair

Subcontractor
Inspected by Date : Name : Signature :
Approved by Date : Name : Signature :
Position :
Contractor
Approved by Date : Name : Signature :
Position :
 PRE-MOBILIZATION / QUARTERLY

Form - 010
Welding Machine

Type of Equipment : CARRY-IN CERTIFICATE

Equipment No. : Permit No. :

Manufacturer :
Approved by :
Company User :
Month of Inspection : Reviewed by
This form must be completed by the operator and company user before entering the equipment to be operated in the
site project area, and at any time of setting location. All equipment condition must meet to the safety regulation and
IKPT SHE Management Plan

Result column: (  ) Yes/Good, Acceptable, ( X ) Not/Bad, Not to use, ( NA ) Not applicable

No Check Item Result Remarks

1 Arc Welding Machine

Appearance
Frame (Body) Earth
Skid/Wheels
Adjust Handle
Installation/Fixing
Automatic Voltage Reducer
2 Cable/Connector
Supply Cables
Earth (Return) Cable
Cable Connectors
Cable Termination/Clamp
3 Electrode Holder condition
4 Fire Extinguisher

INSPECTOR REPORT
Corrective Action Required

Inspection Status:  OK  Not OK  Order for Repair

Subcontractor
Inspected by Date : Name : Signature :

Approved by Date : Name : Signature :

Contractor
Approved by Date : Name : Signature :
Position :

Form - 011
 PRE-MOBILIZATION / QUARTERLY

Engine Welder

Type of Equipment : CARRY-IN CERTIFICATE

Equipment No. : Permit No. :

Manufacturer :
Approved by :
Company User :
Month of Inspection : Reviewed by :
This form must be completed by the operator and company user before entering the equipment to be operated in the
site project area, and at any time of setting location. All equipment condition must meet to the safety regulation and
IKPT SHE Management Plan

Result column: (  ) Yes/Good, Acceptable, ( X ) Not/Bad, Not to use, ( NA ) Not applicable

No Check Item Result Remarks

1 Engine Welder
Appearance
Cooling System
Fuel System
Exhaust System
Starter motor/Dynamo
2 Cable/Connector system
3 Earth (Return) Cable
4 Frame (Body) Earth
5 Career/Wheels
6 Pilot Lamps
7 Meters (Ampere/Volt Meters)
8 Breaker (Emergency Stopper)
9 Safe Guards for moving parts

INSPECTOR REPORT
Corrective Action Required

Inspection Status:  OK  Not OK  Order for Repair

Subcontractor
Inspected by Date : Name : Signature :
Position :
Approved by Date : Name : Signature :
Position :
Contractor
Approved by Date : Name : Signature :
Position :

Form - 012
Gas Cutting / Welding
 PRE-MOBILIZATION / QUARTERLY

Type of Equipment : CARRY-IN CERTIFICATE

Equipment No. : Permit No. :

Company User : Approved by :
Month of Inspection : Reviewed by :
This form must be completed by the operator and company user before entering the equipment to be operated in the
site project area, and at any time of setting location. All equipment condition must meet to the safety regulation and
IKPT SHE Management Plan

Result column: (  ) Yes/Good, Acceptable, ( X ) Not/Bad, Not to use, ( NA ) Not applicable

No Check Item Result Remarks

1 Gas Cylinders
2 Regulator/Hoses/Torches
Regulator
Hoses/Connector
Torches
Flash-back Arrestor
3 Miscellaneous
Fire extinguisher
Fire prevention
Overturn Prevention
Provision of Soap Liquid

INSPECTOR REPORT
Corrective Action Required

Inspection Status:  OK  Not OK  Order for Repair

Subcontractor
Inspected by Date : Name : Signature :
Position :
Approved by Date : Name : Signature :
Position :
Contractor
Approved by Date : Name : Signature :
Position :

Form - 013

Sling / Wire Rope

 PRE-MOBILIZATION / QUARTERLY

Inspector Subcontractor Work Team Inspect. Date Color Code of Remarks

The Month

Number of Inspected Accepted Rejected

Wire Sling
Web Sling

Result column: (  ) Yes/Good, Acceptable, ( X ) Not/Bad, Not to use, ( NA ) Not applicable

No Check Item Sling No.

1 2 3 4 5 6 7 8

1 Wire Sling (Size)

Location or User
a Reduction of Dia. ≧7%
b Damage of Strands≧10%
c Kink or Deformed
d Corroded

Judgment
2 Web Sling (Dimension)
Location or User
a Abrasion, Cut or Burnt
b Cut of Seam or Peeled
c Napped to seam

Judgment

 When one crack of web sling is over 10% in width, or 25% in thickness, or 5 or more cracks are over 3% in width
or 1% in thickness, The Web sling shall be rejected.

Subcontractor
Inspected by Date : Name : Signature :
Position :
Approved by Date : Name : Signature :
Position :
Contractor
Approved by Date : Name : Signature :
Position :

Form - 014
Vehicle
 PRE-MOBILIZATION / QUARTERLY

□ Dump Truck □ Truck □ Trailer □ Truck Mixer

Type of Equipment : CARRY-IN CERTIFICATE

Equipment No. : Permit No. :

Capacity : Date :
Manufacturer :
Approved by :
Company User :
Certificate Number :
Reviewed by :
Month of Inspection :
This form must be completed by the operator and company user before entering the equipment to be operated in the
site project area, and at any time of setting location. All equipment condition must meet to the safety regulation and
IKPT SHE Management Plan

Result column: (  ) Yes/Good, Acceptable, ( X ) Not/Bad, Not to use, ( NA ) Not applicable

No Check Item Result Remarks

1 Carrier Body/Frame
2 Wheels
3 Handle/Power Steering
4 Foot/Hand Brakes
5 Clutch/lever/Pedals
6 Engine
7 Battery/Wiring
8 Engine Oil/Filter/Piping
9 Fuel Tank/Pump/Filter/Piping
10 Radiator/Pump/Fan Belt
11 Transmission/Torque Converter
12 Muffler/Flame Arrestor
13 Lamps
14 Signal Lights
15 Horn/Reverse Alarm
16 Wiper/Washers/Mirrors
17 Door Latches/Locks
18 Seat Belts
19 Fire Extinguisher

INSPECTOR REPORT
Corrective Action Required
 PRE-MOBILIZATION / QUARTERLY

Inspection Status:  OK

 Not OK

 Order for Repair

Subcontractor
Inspected by Date : Name : Signature :
Position :
Approved by Date : Name : Signature :
Position :
Contractor
Inspector Date : Name : Signature :
Position :
Approved by Date : Name : Signature :
Position :

Form - 015
Compressor

Type of Equipment : CARRY-IN CERTIFICATE

 PRE-MOBILIZATION / QUARTERLY

Equipment No. : Permit No. :

Manufacturer :
Approved by :
Company User :
Month of Inspection : Reviewed by :
This form must be completed by the operator and company user before entering the equipment to be operated in the
site project area, and at any time of setting location. All equipment condition must meet to the safety regulation and
IKPT SHE Management Plan

Result column: (  ) Yes/Good, Acceptable, ( X ) Not/Bad, Not to use, ( NA ) Not applicable

No Check Item Result Remarks

1 Engine
Cooling & Fuel System
Exhaust System
Starter motor/Dynamo
2 Frame (Body) Earth
3 Career/Wheels
4 Pilot Lamps
5 Cylinder Case
6 Housing
7 Safety Valve/ Un loader Valve
8 Air Receiver
9 Air Cock/Drain Cock
10 Safe Guards for moving parts

INSPECTOR REPORT
Corrective Action Required

Inspection Status:  OK  Not OK  Order for Repair

Subcontractor
Inspected by Date : Name : Signature :
Position :
Approved by Date : Name : Signature :
Position :
Contractor
Approved by Date : Name : Signature :
Position :

Form – 016
Generator

Type of Equipment : CARRY-IN CERTIFICATE

 PRE-MOBILIZATION / QUARTERLY

Equipment No. : Permit No. :

Manufacturer :
Approved by :
Company User :
Month of Inspection : Reviewed by :
This form must be completed by the operator and company user before entering the equipment to be operated in the
site project area, and at any time of setting location. All equipment condition must meet to the safety regulation and
IKPT SHE Management Plan

Result column: (  ) Yes/Good, Acceptable, ( X ) Not/Bad, Not to use, ( NA ) Not applicable

No Check Item Result Remarks

1 Engine
Cooling System
Fuel System
Exhaust System
Starter motor/Dynamo
2 Outlet Terminal/Wires
3 Frame (Body) Earth
4 Grounding for Enclosure
5 Career/Wheels
6 Pilot Lamps
7 Meters (Ampere/Volt Meters)
8 Breaker (Emergency Stopper)
9 Safe Guards for moving parts

INSPECTOR REPORT
Corrective Action Required

Inspection Status:  OK  Not OK  Order for Repair

Subcontractor
Inspected by Date : Name : Signature :
Position :
Approved by Date : Name : Signature :
Position :
Contractor
Approved by Date : Name : Signature :
Position :

Form – 017
Chain Block

Type of Equipment : CARRY-IN CERTIFICATE

Equipment No. : Permit No. :

 PRE-MOBILIZATION / QUARTERLY

Manufacturer :
Approved by :
Company User :
Capacity : Reviewed by :
Month of Inspection :
This form must be completed by the operator and company user before entering the equipment to be operated in the
site project area, and at any time of setting location. All equipment condition must meet to the safety regulation and
IKPT SHE Management Plan

Result column: (  ) Yes/Good, Acceptable, ( X ) Not/Bad, Not to use, ( NA ) Not applicable

No Check Item Result Remarks

1 Block Hook
2 Main Block Cover
3 Sieve
4 Main Chain Sling
5 Driver Chain Sling
6 Safety Latch / PIN
7 Locked Out System

INSPECTOR REPORT
Corrective Action Required

Inspection Status:  OK

 Not OK

 Order for Repair

Subcontractor
Inspected by Date : Name : Signature :
Position :
Approved by Date : Name : Signature :
Position :
Contractor
Approved by Date : Name : Signature :
Position :

Form – 018

Mobile Lift

Type of Equipment : CARRY-IN CERTIFICATE

Equipment No. : Permit No. :

Capacity : Date :
 PRE-MOBILIZATION / QUARTERLY

Manufacturer :
Approved by :
Company User :
Month of Inspection : Reviewed by :
This form must be completed by the operator and company user before entering the equipment to be operated in the
site project area, and at any time of setting location. All equipment condition must meet to the safety regulation and
IKPT SHE Management Plan

Result column: (  ) Yes/Good, Acceptable, ( X ) Not/Bad, Not to use, ( NA ) Not applicable

No Check Item Result Remarks

1 Career
Steering
Wheels
Brake, Brake Pedal/Lever
Clutch/Brake
Signals/Horn
Lights
Outriggers/Timber Pads
2 Lift Operating Devices
Levers
Brakes
Emergency Stopper
Telescope Cylinder
Scissors Boom
Man-basket
Basket Balance/Moving Device
3 Safety Devices
Operator’s Name
Warning Signs
Carry-in Certificate
Safe Guards for moving parts

INSPECTOR REPORT
Corrective Action Required
 PRE-MOBILIZATION / QUARTERLY

Inspection Status:  OK

 Not OK

 Order for Repair

Subcontractor
Inspected by Date : Name : Signature :
Position :
Approved by Date : Name : Signature :
Position :
Contractor
Inspector Date : Name : Signature :
Position :
Approved by Date : Name : Signature :
Position :

Form – 019
Gondola / Cargo Lift

□ Gondola □ Cargo Lift

Type of Equipment : CARRY-IN CERTIFICATE

Equipment No. : Permit No. :

Capacity : Date :
 PRE-MOBILIZATION / QUARTERLY

Manufacturer :
Approved by :
Company User :
Month of Inspection : Reviewed by :
This form must be completed by the operator and company user before entering the equipment to be operated in the
site project area, and at any time of setting location. All equipment condition must meet to the safety regulation and
IKPT SHE Management Plan

Result column: (  ) Yes/Good, Acceptable, ( X ) Not/Bad, Not to use, ( NA ) Not applicable

No Check Item Result Remarks

1 Gondola/Lift
Overhang Support Arms
Wire Ropes/Shackles
Reel Winding/Sheaves
Electro/Mechanic Brakes
Hand Control Device
Stopper/Latches
Cage/Handrail
Bolts/Nuts/Bearing
Control Panel
Motor
Cab tire Cable/Earth
Over-Wind Warning Devices
Emergency Stopper
Lift: Guide Rails/Support
Shuttering Doors
Safe Guards for moving parts
2 Indication/Signs
Operator’s Name
Weight/Person No. Limitation
Warning Signs

INSPECTOR REPORT
Corrective Action Required
 PRE-MOBILIZATION / QUARTERLY

Inspection Status:  OK

 Not OK

 Order for Repair

Subcontractor
Inspected by Date : Name : Signature :
Position :
Approved by Date : Name : Signature :
Position :
Contractor
Inspector Date : Name : Signature :
Position :
Approved by Date : Name : Signature :
Position :