Inspection Date :

UNIQUE CRANE Capacity :

Owner :
INSPECTION STANDARD User Dept :
(PER.05/MEN/1985 PESAWAT ANGKAT DAN ANGKUT) TEIR No :
INSPECTION METHOD INSPECTION RESULT
No INSPECTION ITEM STANDARDS REASON FOR NOT COMPLY
VISUAL FUNCTION CONT ULI
Common
are inflated and free of excessive wear or damage. Nuts are tight (tidak
1 wheel Tire (ban)
kempes dan rusak.baut rapat, roda depan bukan vulkanisir) ▪
2 Fuel tank cover (tutup bahan bakar) tight,manufacturing standard (rapat,standard pabrikan)
▪
3 Fuel tank (tangki bahan bakar) no leak (tidak bocor) ▪
cover all surface,isolator matrial (menutupi seluruh permukaan,terbuat
4 battery cover (tutup accu)
dari bahan isolator) ▪
5 Rearviwe mirror (kaca spion) clearly (jelas) ▪
6 Horn (klakson) work (berfungsi)
▪
easy start and stop, no spark (mudah dihidup dan matikan,tidak ada
7 Engine (mesin)
percikan) ▪
Brake,Parking brake (rem,rem
8 work (berfungsi)
parkir/handrem) ▪
9 Headlamp (lampu utama) work (berfungsi)
▪
10 Signal lamp (lampu sein) work (berfungsi)
▪ `
11 Radiator above min.level (diatas ambang batas min)
▪
Gauge indicator cabin (panel
12 work (berfungsi)
indikator kabin) ▪
13 License of driver (SIM) valid (min.B2)
▪
14 Emission gas (emisi gas) pass from DISHUB (lulus dari DISHUB)
▪
15 Wiper work (berfungsi)
▪
Special Requirement

1 Hydroulic system (sistem hidrolik) no leak,work and smothly (tidak bocor,berfungsi dan lancar)
▪
2 Oil hydroulic (oli hirolik) above min.level (diatas ambang batas min)
▪
work,greased,safety lack work,not crack,bent (berfungsi,greasing,safty
3 Hook (gantungan)
lacknya berfungsi,tidak retak,bengkok)
▪
4 Fire extinguisher (APAR) still segel and not expired (tersegel dan tidak kadaluarsa)
▪
Certificate unique crane truck
5 valid from DISNAKER ( valid dari DISNAKER)
(sertifikat perlatan) ▪

INSPECTION STATUS
PASSED Stiker Number

HOLD Stiker Number

REJECTED Stiker Number

INSPECTION DURATION TO

SPECIAL NOTE FROM ULI : SIGNAL LAMP

HYDROLIC LEGHT

INSPECTION BY APPROVED BY

Name and Signature Name and Signature

ULI-WALLSICF-SAF-FORM010 Ver.0.0 26 May 2023