FOR NEAR COASTAL VOYAGE

VESSEL NAME

CSD GALILEO

CONTRACT NUMBER

4420001465A
17-May-16

DATE

MARINE CREW MATRIX COMPETENCIES DECLARATION FORM

I, as the Contract Manager / Representative of PT.PT SAMUDERA ENERGI TANGGUH For Service Contract No.4420001465A hereby declare that personnel listed below have been assessed and confirms where meet with the Company's Standard and/Or STCW '95 of competency, safety behavior and health to work at BP Tangguh. All listed personnel have been explained in
regards to scope of work, execution plan, risk assessment, operating procedure, tools/equipment in use and the emergency procedure.
I am fully responsible for the validity of information given hereby and will ensure the compliance of this declaration.

BP Marine AsPac ADDITIONAL REQUIREMENTS TO CMID / OVID

Name

Position

Years Experience
on
Similiar vessel
(min 5 years)

Seaman
Book

Certificate of
Competency
(ANT/ATT)

Certificate
Number

Endorseme
nt
License

Years - Month

No & Exp date

Class &
Issued date

10 digit

Proficiency Certificate (STCW' 95) with validity max. 5 years

Other Certificate
MCU

Lifting &
Rigger's Cert

SSO

ISM Code

TF
(If Tanker)

OT
BRM / ERM
(If Tanker)

Expired date

Expired date

Expired date

Expired date

Expired date

Expired date

Expired date

Expired date

02-04-17

21-04-17
03-12-16

05-06-20

26-11-15

06-12-15

07-04-20

28-03-19

02-11-20

17-12-17

20-09-18

BST

SCRB

MFA

MC

AFF

RADAR

ARPA
(If
installed)

GMDSS

GOC / ORU

Expired date

Expired date

Expired date

Expired date

Expired date

Expired date

Expired date

Expired date

Expired date

26-11-19
01-04-21

04-12-19
15-03-21

04-12-19
17-03-21

14-08-20

02-12-19
14-03-21

20-08-20

19-08-20

07-03-21

Dolfi D Sampelan
Roy Marthen

Master
Chief Officer
2nd Officer
3rd Officer

A031712
E036320

ANT IV
ANT V

6200083915
6200140292

28-10-20
20-01-17

DEDY

Chief Engineer

W052594

ATT IV

6200500749

04-12-20

11-03-20

15-03-20

01-12-21

03-12-17

10-12-17

17-09-16

Endro Wiyono

2nd Engineer

C074610

ATT V

6200346628

03-02-21

28-04-19

26-07-16

07-07-16

19-10-20

11-11-16

21-04-17

ECDIS

CT
(If Tanker)

CM

CMHB

Expired date

Expired date

Expired date

Expired date

01-12-16

3rd Engineer
Bosun
SUKAMTO

Operator 1

E078334

6211568346

27-01-21

Luhur Budi

Operator 2

E078332

6211568338

27-01-21

Nelson

Operator 3

D057791

6202112426

25-09-18

Abdul Basir
Setio Widodo
Budi Adhi

Oiler 1
Oiler 2
Dackhand 1
Dackhand 2
Mekanik

E078333
E078336
E078335

6211568328
6211568344
6211568329

27-01-21
27-01-21
27-01-21

21-04-17
01-04-17
21-04-17

Suryono Leonard

Cook
Messboy
Deck Cadet
Engine Cadet
Project Manager

27-01-21

21-04-17

SYAHRUDDIN

Construction Manager

27-01-21

21-04-17

27-01-21

06-04-17

27-01-21

06-04-17

Sangkala Gaffar
IRMAN SADANA

Surveyor
Assistant Surveyor

ANT D

01-04-17
06-04-17
02-03-20

26-03-20

06-03-20

07-04-17

During the project OR operation's execution, the listed personnel will comply with the following requirements to ensure all activities can be safely completed.
1. Adherence to the whole process of Permit To Work (PTW), Operating Procedures, HSE requirments, Good Safety behavior practices and accept all consuequences of procedure / regulation violation.
2. Stop the job and immediately to report to Master or Supervisor for any further risk assessment for any unsafe conditions or inconsistencies with the plan as outlined in the PTW (i.e. changing the plan or scope of work or sequence, tools / equipment break down, uncertain or in doubt on executing the job, presence of new hazards).
3. Aware of the hazard, write them down on Level 1 or L2RA and implement the mitigation during work planning, preparation, execution, usage of equipment include other chemical and other hazardous materials (refer to MSDS) if any.

Declared by,

Endorsed by,

Mahmud Tarmizi Amir

President Director

Muchtar Harris
Contract Accountable Manager