Title Page

  • Site conducted

  • Prepared by

  • Fecha

  • Fase

  • Punto Kilometrico

  • Location
  • Responsable HKC

  • Responsable OPCEM

  • Tipo de Mantenimiento

  • Hora de inicio del mantto

Datos del Dispositivo

  • Estado Fisico del Elemento

  • Descripcion de falla

  • Evidencia Fotografica

  • Acciones a Realizar

  • Observaciones

  • Evidencia Fotografica Despues Del Mantto

  • Nombre de operador que valida en CCO

  • Hora de finalizacion

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