Form No.

PC200-8/3465/00/QA10/13
DAILY INSPECTION SHEET
WO/JO NO.
QA 10 MAINTENANCE SHEET PC 200-8

Date
Zone 2 : lower Rear Area Code Unit
S/N Unit
SMR
Location
Inspection time start : Time finish :

Condition Note Priority

G Good Condition 1 Leaking 5 Worn 1 Action now
B Bad Condition 2 Broken 6 Crack 2 Action at change shift
U Unchecked 3 Missing 7 Others 3 Action on next PS
4 Loose 4 Action on schedule backlog
Beri tanda (V) pada kolom sesuai dengan kondisi
Pada kolom foto cantumkan nomor image yang sesuai dengan kondisi

Condition Note Priority

No Description Remark Foto
G B U 1 2 3 4 5 6 7 1 2 3 4
A. Bucket Area
1 Bucket
2 Link Bucket
3 Teeth Bucket
5 Pin Bucket
7 Hose Grease Pin
B. Cylinder Attachment Area
1 Boom Cylinder RH
2 Boom Cylinder LH
3 Bucket Cylinder
4 Arm Cylinder
C. Working Attachment Area
1 Boom Attachment
2 Arm Attachment
3 LH lock pin boom pivot
4 RH lock pin boom pivot
D.Central Frame Area
1 Tighten Frame Std :
2 Tube and nipple grease
3 Swivel Joint
4 Swing motor
5 Swing Machinery
6 Level Swing Machinery Low : Med : High :
7 Swing Circle
E. Control valve Area
1 Control Valve
2 Related Hose of C/V
3 Electric Sensor & Wiring Condition
4 Piping around control valve
F. Track Group Area
1 Track Frame RH
2 Idler RH
3 Tension of Track RH
4 Track Roller RH
5 Carrier Roller RH
6 Track Shoe RH
7 Shoe Bolt RH
8 Track Link RH
9 Sprocket RH
10 Travel Motor RH
11 Level Final drive RH Low : Med : High :
12 Cover RH
13 Track Frame LH
14 Idler LH
15 Tension of Track LH
16 Track Roller LH
17 Carrier Roller LH
18 Track Shoe LH
19 Shoe Bolt LH
20 Track Link LH
21 Sprocket LH
22 Travel Motor LH
23 Level Final drive LH Low : Med : High :
24 Cover LH

No Additional of Fluid (Oil,Coolant,Grease ) Quantity ( Liter )

1
2
3
4
5

Operator Name : Signature Mechanic Name Supervisor Name

Comment : Signature : Signature :

Sign Date : Sign Date :