| TANGGAL P2H | |
| NO.POLISI |
* Ketik No Plat, Lalu Klik No Plat Yang Muncul Dibawah |
| NO.LAMBUNG/NO.ASET | |
| JENIS | |
| PIC SARANA | |
| JOBSITE | |
| STNK |
* Tanggal Akhir Masa Berlaku STNK |
| PAJAK |
* Tanggal Akhir Masa Berlaku Pajak |
| KIR |
* Tanggal Akhir Masa Berlaku KIR (Jika Ada) |
| KM/HM AKTUAL |
* KM Aktual Sekarang Yang Ada Didashboot mobil/Spedometer |
| KM/HM SERVIS |
* KM yang ada dikertas servis berkala (Servis Terakhir) |
| KONDISI UNIT |
RFU RUSAK |
| NO | Bagian(Kode) | Cek | Keterangan | Gambar |
| 1 | Alarm Mundur(B) |
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| 2 | Apar(B) |
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| 3 | Ban & Baut Roda(A) |
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| 4 | Ban Serep(B) |
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| 5 | Buggy Whip(A) |
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| 6 | Dongkrak dan Penyangga(B) |
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| 7 | Double Gardan/Sistem 4 WD(C) |
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| 8 | Kaca Cabin(AA) |
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| 9 | Keadaan Body(C) |
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| 10 | Kebersihan Unit(C) |
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*Wajib Foto Untuk(Ya) |
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| 11 | Kelengkapan Surat(AA) |
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| 12 | Klakson(A) |
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| 13 | Kondisi Aki(B) |
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| 14 | Kondisi Rem(AA) |
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| 15 | Kotak P3K(C) |
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| 16 | Lampu Bahaya(B) |
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| 17 | Lampu Rotary(A) |
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| 18 | Lampu Sein(B) |
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| 19 | Lampu Unit/Cabin(A) |
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| 20 | Level Air Radiator(A) |
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| 21 | Level Oli Mesin(AA) |
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| 22 | Level Oli Steering(AA) |
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| 23 | Radio Komunikasi(AA) |
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| 24 | Rem Tangan(A) |
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| 25 | Sabuk Pengaman(A) |
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| 26 | Segitiga Pengaman/Traffic Cone(C) |
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| 27 | Spion Cabin(B) |
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| 28 | Spion LH RH(B) |
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| 29 | Wheel Chock (Ganja Ban)(A) |
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| 30 | Wiper(AA) |
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| Tanggal berapa perkiraan anda akan mengajuakan pengisian BBM | * Hanya Estimasi (Agar GS bisa mempersiapkan) |
| Catatan/Keluhan Kondisi Unit |