INTERMAINT  

Group
TRANSPORT AND HEAVY EQUIPMENT
Document No: SBG‐HSE – 015‐03                                                                                                                     Revision: 7

Date Modified: 22‐05‐2018

EQ Type ‫اﻟﻤﻌﺪة‬ ‫ﻧ ع‬ AMBULANCE Date of inspection  ‫اﻟﻔﺤﺺ‬ ‫ﺗﺎر ــﺦ‬

EQ  S.N ‫ﻟﻠﻤﻌﺪة‬  ‫اﻟ ﺴﻠﺴ‬ ‫اﻟﺮﻗﻢ‬  Inspection No ‫اﻟﻔﺤﺺ‬ ‫رﻗﻢ‬
Manufacture Compa ‫اﻟﻤﺼﻨﻌﺔ‬ ‫اﻟ ﻛﺔ‬ Equipment No  ‫اﻟﻤﻌﺪة‬ ‫رﻗﻢ‬
Operator Name ‫اﻟﻤﺸﻐﻞ‬ ‫إﺳﻢ‬ Driver License No ‫اﻟﺴﺎﺋﻖ‬ ‫رﺧﺼﺔ‬ ‫رﻗﻢ‬
License Car No ‫اﻟﺴ ﺎرة‬ ‫رﺧﺼﺔ‬ ‫رﻗﻢ‬ License EQ Exp Date  ‫اﻧﺘﻬﺎءاﻟﺮﺧﺼﺔ‬ ‫ﺗﺎر ــﺦ‬
Comments ‫ﻣﻼﺣﻈﺎت‬ Maintenance Sheet    ‫اﻟﺼ ﺎﻧﺔ‬ ‫ﺟﺪول‬
1
N/A No Yes

Comments ‫ﻣﻼﺣﻈﺎت‬ Driver License                ‫اﻟﺴﺎﺋﻖ‬ ‫رﺧﺼﺔ‬

2
N/A No Yes

Comments ‫ﻣﻼﺣﻈﺎت‬ Seatbelt                               ‫اﻷﻣﺎن‬ ‫ﺣﺰام‬

3
N/A No Yes

Comments ‫ﻣﻼﺣﻈﺎت‬ Tires                                         ‫اﻹﻃﺎرات‬

4
N/A No Yes

Comments ‫ﻣﻼﺣﻈﺎت‬ Revers Alarm      ‫اﻟﺨﻠﻒ‬  ‫ا‬ ‫اﻟﺮﺟ ع‬ ‫إﻧﺬار‬

5
N/A No Yes

Comments ‫ﻣﻼﺣﻈﺎت‬ Revolving Light                ‫اﻟﻤﺨﺎﻃﺮ‬ ‫إﺿﺎءة‬

6
N/A No Yes

Comments ‫ﻣﻼﺣﻈﺎت‬ Side Mirrors                        ‫اﻟﺠﺎﻧ ﺔ‬ ‫اﻟﻤﺮا ﺎ‬

7
N/A No Yes

Comments ‫ﻣﻼﺣﻈﺎت‬ Horn                                          ‫اﻟﺘ ﺒ ﻪ‬ ‫آﻟﺔ‬

8
N/A No Yes

Comments ‫ﻣﻼﺣﻈﺎت‬ wipers                  ‫اﻷﻣﺎ‬ ‫اﻟﺰﺟﺎج‬ ‫ﻣﺴﺎﺣﺎت‬

9
N/A No Yes

Comments ‫ﻣﻼﺣﻈﺎت‬ Fire Extinguishe                 ‫ﺣ ﻖ‬ ‫ﻃﻔﺎ ﺔ‬

10
N/A No Yes

Comments ‫ﻣﻼﺣﻈﺎت‬ Front & Back Light     ‫وﺧﻠﻔ ﺔ‬ ‫أﻣﺎﻣ ﺔ‬ ‫إﺿﺎءة‬

11
N/A No Yes

Comments ‫ﻣﻼﺣﻈﺎت‬ Oxygen Cylinder            ‫اﻷ ﺴﺠ‬ ‫إﺳﻄﻮاﻧﺔ‬

12
N/A No Yes

Comments ‫ﻣﻼﺣﻈﺎت‬ First Aid Kit          ‫اﻷوﻟ ﺔ‬ ‫اﻹﺳﻌﺎﻓﺎت‬ ‫ﺷﻨﻄﺔ‬ Comments ‫ﻣﻼﺣﻈﺎت‬ Mobile Bed Brakes          ‫اﻟﻨﻘﺎﻟﺔ‬ ‫ﺮ‬  ‫ﻓﺮاﻣﻞ‬

15 13
N/A No Yes N/A No Yes

Comments ‫ﻣﻼﺣﻈﺎت‬ Brake                                                   ‫اﻟﻔﺮاﻣ ــﻞ‬ Comments ‫ﻣﻼﺣﻈﺎت‬ Daily Inspection                      ‫اﻟﻴﻮ‬ ‫اﻟﻔﺤﺺ‬

16 14
N/A No Yes N/A No Yes

Comments : : ‫ﻣﻼﺣﻈﺎت‬

‫اﻟﺘﻮﻗﻴﻊ‬  ‫اﻟﻤﺸﻐﻞ‬ ‫إﺳﻢ‬
Signature Operator Name
‫ﺗﻮﻗ ﻌﻪ‬ ‫اﻟﻤﻌﺪات‬ ‫ﻗﺴﻢ‬ ‫ﻣﺴﺆول‬
‫اﻹﻋﺘﻤﺎد‬

Signature EQ Dep Response
‫ﺗﻮﻗ ﻌﻪ‬ ‫اﻟﺴﻼﻣﺔ‬ ‫ﻣ ف‬
Signature Safety Supervisor
‫ﺗﻮﻗ ﻌﻪ‬ ‫ﻣﺔ‬ ‫اﻟﺴﻼ‬ ‫ﻣﻬﻨﺪس‬
Signature Safety Engineer

 In Case The Equipment Excluded Please Reason For Exclusion  /                      /              : ‫اﻹﺳ ﻌﺎد‬ ‫ﺗﺎر ــﺦ‬ ‫اﻹﺳ ﻌﺎد‬ ‫ﺳ ﺐ‬ ‫ذﻛﺮ‬ ‫اﻟﺮﺟﺎء‬ ‫اﻟﻤﻌﺪة‬ ‫إﺳ ﻌﺎد‬  ‫ﺣﺎل‬ 

‫اﻟﺘﻨﻔ ﺬي‬ ‫اﻟﻤﺪﻳﺮ‬          ‫اﻟﺴﻼﻣﺔ‬ ‫ﻣﺪﻳﺮ‬             ‫اﻟﺴﻼﻣﺔ‬ ‫ﻣﻬﻨﺪس‬ 

‫اﻹﻋﺘﻤﺎد‬

Constructio Manager  Safety Manager      Safety Engineer 

‫ﺗﻮﻗ ﻌﻪ‬ ‫ﺗﻮﻗ ﻌﻪ‬ ‫ﺗﻮﻗ ﻌﻪ‬
Signature Signature Signature

Archive Received Date   :                     /                 /                   /                /               : ‫ﺑﺘﺎر ــﺦ‬ ‫اﻷرﺷ ﻒ‬ ‫إﺳﺘﻼم‬

At The Time Of Inspection, This Equipment Was Safe For Work On The Project  ‫اﻟﻔﺤﺺ‬ ‫وﻗﺖ‬ ‫أﺛﻨﺎء‬ ‫وع‬ ‫ ﺎﻟﻤ‬ ‫ﻟﻠﻌﻤﻞ‬ ‫آﻣﻨﺔ‬ ‫اﻟﻤﻌﺪة‬ ‫ﻫﺬە‬