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Ph Lc 4A/ Appendix No.

4A
(Ban hnh km theo Ngh nh s 209/2004/N-CP ngy 16/12/2004 ca Chnh ph /
this appendix was attached with decree No. 209/2004/NDD-CP date 16/12/2004 of Vietnams
Government)

cng ho x hi ch ngha vit nam


c lp - T do - Hnh phc
----------------Hi phng, ngy/day....... thng/month....... nm/year 2007
Bin bn s/ Minute No.:

Nghim thu ni b cng vic xy dng


(Contractors Internal acceptance of completed construction works)
Cng trnh/Poject : Ci to nh my nc Cu Nguyt v XD mng li cp nc Kin
An, HP.
Rehabilitation of Cau Nguyet WTP and Construction of Network in Kien
An, Haiphong city.
Hng mc/ Item : ...

a im/ Location : ..

1. i tng nghim thu/ inspection object: Cng tc lp t ng v ph kin


tuyn

ng/

Works

installation

of

pipes

and

fittings

for

pipeline :

..
- Mng o t ng
t ng v ph kin

- Ct ph ng v cng tc m
t tm an cnh bo

- Ct lt ng v cng tc m

- Lp t bng cnh bo

- Lp

- Lp

2. Thnh phn trc tip nghim thu/participants take part in the inspection:
a) ban iu hnh d n ca TCT viwaseen/ Viwaseens Site Management Board:
ng/B (Mr/Mrs):

Chc v/position:..

ng/B (Mr/Mrs):

Chc v/position:..

b) n v thi cng/ Construction Team.


ng/B (Mr/Mrs):

Chc v/position:..

ng/B (Mr/Mrs):

Chc v/position:..

3. Thi gian nghim thu/inspection time:


Bt u/start at :
200..

.......... ngy/day.........thng/month........ nm/year

Kt thc/finished at : .......... ngy/day.........thng/month........ nm/year 200..


Ti/Inspection
..

position:

...............................................................................................................................
..................................
4. nh gi cng vic xy dng thc hin/Remarks about the works done:
a) V ti liu lm cn c nghim thu/About the documents for inspection:
-

Bin bn nghim thu vt liu, sn phm ch to sn trc khi s dng/


Minute for acceptance of pre-fabrication material and equipments:

H s thit k bn v thi cng c ch u t ph duyt v nhng thay


i thit k/ for construction drawing and design variations:
...

.....................................................................................................................
................................
-

Quy
chun,
tiu
chun
....

dng/application

standard:

.....................................................................................................................
................................
-

Ti liu ch dn k thut km theo hp ng/ technical specification


attached with contract:

Mc 3, tp 2 phn quy cch lp t ng/ Sub-clause 3, part 2 of


technical specification
-

Cc kt qu kim tra, th nghim cht lng vt liu, thit b c thc


hin trong qu trnh thi cng/Certificates, results of checking and testing
that carry out during the construction time:

.....................................................................................................................
................................
.....................................................................................................................
................................
-

Nht k thi cng ca n v thi cng trc tip v cc vn bn khc c


lin quan n i tng nghim thu/ site dairy of supplier and all other
documents related to inspection object:

.....................................................................................................................
...............................
b) V cht lng thi cng/ About quality of the construction work:
......
.
c)
Cc

kin
khc
nu
c/

other

ideal

(if

any):

.
.
d) kin ca Ban iu hnh d n v cng tc nghim thu cng vic xy
dng ca n v thi cng/
comments about inspection of construction works:
.

.
.
5. Kt lun/ conclusion:
.
.
.
Execution engineer in charge
Cn b thi cng trc tip

Site management board of viwaseen


Cn b ban HDA CN kin an

Cc ti liu km theo/ attached documents :


.
.