INSTRUCTIONS:

1. This form must be included for all proposed corrective actions submitted after Juli 27, 2016, (1) and should be
included with technical documents related to the below referenced phases.
2. Detail each proposed activity on a separate line and provide a detailed description of each in the appropriate field.
3. Table 1 is to provide a detailed breakdown of proposed work activities utilizing

NOTE:

This form does not constitute pre-approval of corrective action related costs.

SUBMIT
COMPLETED
FORM TO:

CV. TABIR JAYA MANDIRI

Attention: Dwi Lingga Prabowo
Jln. Raya Karangampel Jatibarang Gg. 4 Utara
No. 22 RT/RW. 009/003 45283 Karangampel Lor
Indramayu, Jawa Barat

RP Name:
RP
Address:

DPRD..........

RP Phone:

( 0234 ).............

JALAN...........

Site Name:

Facility ID Number:

..............

Incident Number:

..............

Dprd......

Site Address:

http\\................

Contact Name:

ZAENAL...........

[RP = Responsible Party]

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TABLE 1
Proposed Scope of Work Details
Proposed
Units

Unit Type

Activity
Code

Activity and Detailed Description

IDEM
Adjusted
Units

2 of 3

3 of 3