PT Dutikon PT.

SWADAYA GRAHA
JL.RAYA MARGOREJO INDAH A-114 (SEMEN INDONESIA GROUP)
Phone(031)8434744-8438918 Fax.8490443 JL. RA. KARTINI 25 GRESIK
SURABAYA MATERIAL APPROVAL
Proyek : Pembuatan Dinding Penahan Garasi Truck Unit VI
No. : /UNIT VI/12.15
Date : 15 Desember 2015

ITEM DESCRIPTION
1. MATERIAL : …………………v……………….
Mix design 2. TEST DATA : …………………………………..
3. DIMENSION : …………………………………..
Location : Unit VI 4. OTHER INFORMATIAN : …………………………………..

SHORT DESCRIPTION OF MATERIAL

MIX DESIGN SUBMISSION K-300 (Terlampir)

MANUFACTURER: ……………………………………………………..
DISTRIBUTOR / SUPLIER ( Name, Address, Phone, etc)

SNI BETON 7384 : 2008

ATTACHMENT :

Requested by : PT. Swadaya Graha

Date : 15 Desember 2015
COMMENT : PT. SWADAYA GRAHA
………………………………………………………………………………… Approved / Not Approved
…………………………………………………………………………………
…………………………………………………………………………………
…………………………………………………………………………………
…………………………………………………………………………………
………………………………………………………………………………… Name : …………………………..
………………………………………………………………………………… Date : …………………………..

COMMENT : PT. DUTIKON SEJAHTERA

……………………………………………………………………………….. Approved / Not Approved
………………………………………………………………………………..
………………………………………………………………………………..
………………………………………………………………………………..
………………………………………………………………………………..
……………………………………………………………………………….. Name : …………………………..
……………………………………………………………………………….. Date : …………………………..
 PT Dutikon PT. SWADAYA GRAHA
JL.RAYA MARGOREJO INDAH A-114 (SEMEN GRESIK GROUP)
Phone(031)8434744-8438918 Fax.8490443 JL. RA. KARTINI 25 GRESIK

SURABAYA MATERIAL APPROVAL

Proyek : Jembatan Tengah Surya Inti Tembakau
No. : 002/LPM/01.13
Date : 28 Januari 2013

ITEM DESCRIPTION
1. MATERIAL : …………………v……………….
Bata Merah 2. TEST DATA : …………………………………..
3. DIMENSION : …………………………………..
Location : Surya Inti Tembakau 4. OTHER INFORMATIAN : …………………………………..

SHORT DESCRIPTION OF MATERIAL

1 Bata Merah Uk. 22 x 10 x 45 cm

MANUFACTURER: ……………………………………………………..
DISTRIBUTOR / SUPLIER ( Name, Address, Phone, etc)

1 UD Mulyo
Desa Ngebrak
Telp. 085 856 468 052

ATTACHMENT :

Requested by : PT. Swadaya Graha

Date : 28 Januari 2013
COMMENT : CONSULTANT SUPERVISI :
………………………………………………………………………………… Approved / Not Approved
…………………………………………………………………………………
…………………………………………………………………………………
…………………………………………………………………………………
…………………………………………………………………………………
………………………………………………………………………………… Name : …………………………..
………………………………………………………………………………… Date : …………………………..

COMMENT : OWNER :
……………………………………………………………………………….. Approved / Not Approved
………………………………………………………………………………..
………………………………………………………………………………..
………………………………………………………………………………..
………………………………………………………………………………..
……………………………………………………………………………….. Name : …………………………..
……………………………………………………………………………….. Date : …………………………..
 SURAT PENGANTAR

No : /UNIT VI/12.15
Tanggal : 15 Desember 2015
Kepada : PT Dutikon Sejahera
Alamat : Pembuatan Dinding Penahan Garasi Truck Unit VI

NO ISI DOKUMEN JUMLAH SATUAN KETERANGAN

1 Lembar approval material 1 Lbr

2 Surat jalan besi tgl 24 Juni 2011 1 Lbr
3 Surat jalan besi tgl 25 Juni 2011 1 Lbr
4 Certificate 0f Quantity and Quality tgl 25 Juni 2011 1 Lbr
5 Surat jalan besi tgl 30 Juni 2011 1 Lbr

Penerima Pengirim

( ) ( Suyitno )

Tanggal Terima :

Jam Terima :
PT. SWADAYA GRAHA
( SEMEN GRESIK GROUP )

LEMBAR PERSETUJUAN MATERIAL

PROYEK : Pembangunan Gudang Rokok Unit III TANGGAL :

PELANGGAN : PT. Gudang Garam, Tbk. No. Ref. Gbr. :

LOKASI : Jl.Raya Semampir No.01 Kediri No. pengajuan :

ITEM : Besi beton ulir

MATERIAL : Besi beton ulir

DIAJUKAN NO URAIAN SATUAN HARSAT KETERANGA

1 Besi beton ulir dia 16mmx12m Ljr - Sesuai Surat jalan & Certifi

2 Besi beton ulir dia 22mmx12m Ljr - Ex PT Hanil Jaya Steel SNI

3 Besi beton ulir dia 25mmx12m Ljr

KOMENTAR :

DIAJUKAN OLEH ( PT. SWG )

Tanda Tangan :

Suyitno
Tanggal : 06 Juli 2011
DICEK / DISETUJUI OLEH
Tanda Tangan :

Tanggal :
RSETUJUAN MATERIAL
06 Juli 2011

002/LPM/GG/07.11

KETERANGAN

- Sesuai Surat jalan & Certificate terlampir

- Ex PT Hanil Jaya Steel SNI