EQUIPMENT PRE - INSPECTION REPORT

(Prime Mover / Winch Truck)

ASSET NO. : INSPECTION DATE :

TYPE / MODEL : LOCATION :
MAKE / YEAR : ENGINE/SERIAL NO. :
SERIAL NUMBER : KM / HOUR METER :
CONTRACT NUMBER : USER / OWNER :

CONDITION
NO. COMPONENT GROUP ACCEPTABLE UNACCEPTABLE
REMARK
(BISA DITERIMA) (TIDAK BISA DITERIMA)

ACCESSORIES
1 Fire Extinguisher      
2 First Aid Kit      
3 Safety Triangular
4 Tire chock
5 Painting number of assets      

ENGINE
1 Engine Performance      
2 Fuel System      
§  Fuel tank      
§  Fuel injection      
§  Fuel line      
§  Fuel filter/water separator      
§  Transfer pump      
§  Fuel gauge / Indicator lamp      
3 Lubrication System      
§  Oil pump / filter      
§  Oil pan      
§  Oil pressure gauge / Indicator lamp      
4 Cooling System      
§  Radiator, reservoir, cap      
§  Hose upper / lower      
§  Water pump      
§  Fan & Belt
§  Radiator mounting / guard      
§  Water temperature gauge / Indicator lamp      
5 Induction System      
§  Intake manifold      
§  Air cleaner      
§  Turbo charger      
§  Exhaust manifold      
§  Muffler / Tail / Rain Cap      
6 Crankshaft seal front / rear      
7 Pulley / damper      
HSE FTD/Form Inspection P. Mover / W.Truck Rev-MS-20102014 Page 1 of 4
 8 Engine mounting, bolt front / rear      

POWER TRAIN
1 Clutch / Torque converter      
2 Transmission / Transfer case      
3 Propeller shaft / Support bearing      
4 Differential / front / middle / rear
5 Front axle / seal RH/LH      
6 Middle axle / seal RH/LH      
7 Rear axle / seal RH/LH      
8 Beam / bushing      

CHASIS / BODY
1 Cabin operator      
§  Operator seat / Safety belt
§  Helper seat / Safety belt
§  Dust boot / panel
2 Body / floor / bumper / fender      
3 Body mounting front / rear      
4 Door, lock RH/LH      
5 Mirror RH/LH      
6 Safety mud guard, front / rear      
7 Body painting      
8 Wind shield

SUSPENSION SYSTEM
1 Shock absorber front RH/LH      
2 Shock absorber middle RH/LH
3 Shock absorber rear RH/LH      
4 Spring / pin / bushing front RH/LH      
5 Spring / pin / bushing middle RH/LH      
6 Spring / pin / bushing rear RH/LH      
7 Rubber / stopper front / rear RH/LH      
8 Tire/wheel/bolt/nut front RH/LH      
9 Tire/wheel/bolt/nut/ middle RH LH      
10 Tire / wheel/bolt/nut/rear RH/LH      

STEERING SYSTEM
1 Steering wheel      
2 Steering pump / Reservoir, cap      
3 Steering gear box / pitman, arm      
4 Drag Link      
5 Tie rod / Ball joint      
6 Suction / disc charge line      

BRAKE SYSTEM
1 Air compressor / regulator / tank      
2 Air pressure gauge      
3 Lining brake      

HSE FTD/Form Inspection P. Mover / W.Truck Rev-MS-20102014 Page 2 of 4

 4 Chamber brake      
5 Pedal / Tandem Brake      
6 Parking brake      
7 Engine brake      
8 Front / middle / rear brake performance      
ELECTRIC SYSTEM
1 Battery      
2 Battery box / clamp / cover      
3 Disconnect switch, manual / automatic
4 Terminal / connect cable      
5 Starter motor / Solenoid      
6 Alternator / Charging system      
7 Ampere meter      
8 Starter switch      
9 Head, rear lamp, RH/LH      
10 Brake light, RH/LH
11 Turn signal, front / rear RH/LH      
12 Hazard light      
13 Reverse light sign RH/LH      
14 Reverse alarm sign      
15 Wiper      
16 Instrument panel / Wiring system      
17 Horn      
18 Fuse / cable      
19 AC / blower / Fan      
20 Fuse drive right (0.25A)
WINCH
1 Wire rope hoist / sleeve / hook      
2 PTO/pump/hose/chain/handle brake      
3 Joint shaft      
4 Fitch wheel / pin / dolly      

General Comments :
 

INSPECTION TEAM
Mechanical Inspector User / witness Owner / witness
HSE FTD/Form Inspection P. Mover / W.Truck Rev-MS-20102014 Page 3 of 4
      

RE-INSPECTION TEAM
Mechanical Inspector User / witness Owner / witness
     
     
     
     
General comments :

 
       
Note : Do NOT change the existing system was on a unit that has been passed by the inspection team.
Modifications should only be done by people who are competent and approved by the authorities. Violations of
these rules will apply sanctions in the form "Revocation of Operating Permit Sticker".
Catatan : Dilarang keras merubah sistem yang ada pada unit yang telah dinyatakan lulus oleh Tim Inspeksi.
Modifikasi hanya boleh dilakukan oleh orang yang berkompeten dan disetujui oleh pihak yang berwenang.
Pelanggaran atas aturan tersebut akan diberlakukan sanksi berupa “Pencabutan Sticker Ijin Operasi”.

STICKER VALID UNTIL :

Approved by,

Vicky Rinaldo / Rizki Kushardani

Planing & Logistic Southhern Area Ass. Manager

HSE FTD/Form Inspection P. Mover / W.Truck Rev-MS-20102014 Page 4 of 4