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Form Checklist Hydrant Box

This document is an inspection form for fire hydrant boxes. It lists the location and date of inspection and includes fields to check the condition of the box, valve, nozzle, hose, rack, couplings, and sign as either good (B) or damaged (R). Space is provided to record the inspection of 15 boxes and sign the form.

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prista
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1K views5 pages

Form Checklist Hydrant Box

This document is an inspection form for fire hydrant boxes. It lists the location and date of inspection and includes fields to check the condition of the box, valve, nozzle, hose, rack, couplings, and sign as either good (B) or damaged (R). Space is provided to record the inspection of 15 boxes and sign the form.

Uploaded by

prista
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as XLS, PDF, TXT or read online on Scribd
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FORM FORM

INSPEKSI BOX HYDRANT INSPEKSI BOX HYDRANT

Nomor : Nomor :
Lokasi : Lokasi :
Box Valve Nozzle Hose Rack Coupling Pemerik Box Valve Nozzle Hose Rack Coupling Pemeriks
No. Tgl/Bln/T Paraf No. Tgl/Bln/T Paraf
hn B R B R B R B R B R B R sa hn B R B R B R B R B R B R a

1 1

2 2

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BERILAH TANDA √ BERILAH TANDA √
Keterangan : Keterangan :
B = Baik B = Baik
R = Rusak R = Rusak
RSU KARSA HUSADA BATU
FORM
INSPEKSI BOX HYDRANT
Lokasi :
Peralatan
ADA BATU

DRANT

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