FOR APPROVAL

B 18.OCT.2019 KHASAN GUNA MADE FOR APPROVAL

A 09.OCT.2019 KHASAN GUNA MADE FOR APPROVAL
REV DATE PREPARED CHECKED APPROVED STATUS
Owner

Owner’s Engineer

Contractor

Sub-Supplier

Project

JAWA 9 & 10 COAL FIRED STEAM POWER PLANT

Document Title

ITP FOR INSTALLATION OF STORM WATER WORK

Document Type
□ Basic Engineering Document □ Detail Engineering Document ■ N/A

Document No.

J910-DH02-P0ZEN-049003
 ITP FOR INSTALLATION OF STORM WATER WORK
J910-DH02-P0ZEN-049003

RECORD OF REVISION
Rev. Date Page Affected Description of Revision

A 09.OCT.2019 First Issue

B 18.OCT.2019 7-8, 12, 14 Second Issue

Rev.B 2 of 14
 Jawa 9&10 Coal Fired Steam Power Plant_ITP Comment Sheet
From : O/E Mr. - -
To : HK Mr. I Made Japasunu j_japasunu@yahoo.com Comment Sheet Document No : J910-DH02-P0ZEN-049003_CS
cc : IRT Mr. Steve Adrianto Steve.adrianto@irt.co.id
Doc Title : ITP FOR INSTALLATION OF STORM WATER
Doc No : J910-DH02-P0ZEN-049003
Purpose : FA

Review Category
A = Approved
B = Approved with comments, forward final document C
C = Not Approved
I = Accepted for reference (For information only)

No. Rev. Sheet/ Page/ Sect. O/E Comments Consortium Response Status
1. Update the legend
2. Additional Point for Preparation Works
1 A 7-8/14/- It is applied on Rev. B. Closed
3. Correction on CONTROL DOCUMENT, ACCEPTANCE CRITERIA and
VERIFYING DOCUMENT.
It is applied on Rev. B. We changed Oreintation of spools into Orientation
2 A 12/14/- What is the meaning of Oreintation of spools? Change Slop to Slope Closed
as per drawing.
3 A 14/14/- Ask for Concrete ITP If necessary, ITP for Concrete Work will be applicable. Closed
 ITP FOR INSTALLATION OF STORM WATER WORK
J910-DH02-P0ZEN-049003
TABLE OF CONTENTS

I. INTRODUCTION…………………………………………………………………. 4
1.1.Inspection and Test Plan (ITP)
1.2.Acceptance Conditions
1.3.Request for Inspection and Test (RFI)
1.4.Documentation

II. FLOW CHART OF SITE MATERIAL INSPECTION………………………... 6

III.DETAIL ITP FOR FENCE AND GATE….….………………..…………………7

IV. APPENDICES…………………… ……………………….…………..……………9

Appendix 1
Form No. ITP-C-0001-10 INSPECTION FOR EXCAVATION RECORD REPORT
Appendix 2
Form No. ITP-C-0001-11 INSPECTION FOR BACKFILL RECORD REPORT
Appendix 3
Form No. ITP-C-0001-30 INSPECTION FOR EARTH WORK REPORT
Appendix 4
Form No. ITP-C-0001-31 INSPECTION FOR ERECTION / INSTALLATION REPORT
Appendix 5
Form No. ITP-C-0001-32 INSPECTION FOR JOINT GROUTING REPORT
Appendix 6
Form No. ITP-C-0001-33 INSPECTION FOR BACKFILLING REPORT

Rev.B 3 of 14
 ITP FOR INSTALLATION OF STORM WATER WORK
J910-DH02-P0ZEN-049003
I. INTRODUCTION

1.1. Inspection and Test Plan (ITP)

a. Scope
The Inspection and Test Plan (ITP) is an engineering document, which described the inspection
and tests to be performed. The inspection is performed in accordance with Owner specification
requirements and specified codes & standards.
b. Composition
This ITP is composed as belows:
-Cover Sheet with project name, Owner name, application and related personnel's name.
- Introduction with general notes
- ITP with Inspection and test activities

1.2. Acceptance Conditions

a. The equipments, materials are inspected and tested at Site in confirmation of the conditions
specified in the ITP. Each operation refers to the whole or part of a standard, a technical
specification and a regulation.
b. Detailed Legend
Detailed Legend for Inspection activity points shall be designated on the ITP by the related
parties as follows;
I : Responsible for undertaking Inspection/ Test
Consortium and subcontractor shall perform inspections or tests in accordance with
the contract requirements for each activities.
R : Responsible for Generating Record
Consortium and subcontractor shall make a record for each activities in the form of
documentations and reports.
W : Witness Point
Consortium shall send a notification to the Owner prior to perform the related test
or inspection. If the Owner fails to be present, the test or inspection may be carried
out by Consortium without witness of the Owner.
S/W : Spot Witness Point
The spot witness point that is handled like as a sample witness point, it will be
witnessed by related parties only for several activities/ item to be inspected. But, if
inadequate working procedures are detected by related parties, this point will be
treated as witness points after the proper action.
V : Verification of Record
The result of reports and documentation will be reviewed and approval by the
owner.

Rev.B 4 of 14
 ITP FOR INSTALLATION OF STORM WATER WORK
J910-DH02-P0ZEN-049003
H : Hold Point
Consortium shall also send a notification to the Owner prior to perform the related
test or inspection. If the Owner fails to be present, any construction activities shall
not be proceeded by Consortium without attendence or any written approval of the
Owner.

1.3. Request for Inspection and Test (RFI)

a. RFI will be issued by Consortium in written letter or E-mail or Aconex at least two (2) days in
advance, when the equipments is ready for inspection or test.
b. RFI will contain as a minimum of the following details:
- ITP No./Drawing No./Equiment name/System Name
- Inspection tem/activities on the ITP to be inspected
- Inspection date and time
- Unit No./Area/Building/Location/Elevation
- Any comments to be considered

1.4. Documentation
a. The results of inspections and tests shall be documented in writing and signed by the related
parties as a token of approval
b. Signed documents shall be controlled as a QA records in accordance with the related procedure.

Rev.B 5 of 14
 ITP FOR INSTALLATION OF STORM WATER WORK
J910-DH02-P0ZEN-049003
II. FLOW CHART OF SITE MATERIAL INSPECTION

Flow Chart of Site Material Inspection

SHOP

Engineering Purchase Order Fabrication and Owner Witness Transport,

Design Issue to Manufacturing Inspection as Shipping &
Information as Supplier (PO) in shop per approved Pass Customs
per Contract ITP

SITE

Move to Material &

Warehouse Inspection at Warehouse as per Accept Laydown area Equipment to
Receiving Packing list. or Warehouse be released to
point at Site as per Storage Site
Receiving Inspection report Issue. Levels Construction

Package damaged Re-packing Reject

Open box Inspection

Issue HOLD
Inspection to activity as per
Tag & NCR
check package approved ITP
inside

Rev.B 6 of 14
 ITP FOR INSTALLATION OF STORM WATER WORK
J910-DH02-P0ZEN-049003

III. DETAIL ITP FOR INSTALLATION OF STORM WATER WORK

Document No. : J910-DH02-P0ZEN-049003 Legend : Approved by :
Prepared by : Contractor Verified by :
Owner/Client : PT INDO RAYA TENAGA I : Inspection Owner Third Party
Item No. : R : Responsible
Description : W : Witness
Project Title : Jawa 9 & 10 ( 2x 1000 MW ) CFSPP SW : Spot Witness
Date : V : Verification
Rev. : H : Hold Point
Page No. :

INSPECTION AND TEST PLAN FOR INSTALLATION OF STORM WATER WORK

INSPECTION
REF PROCESS DESCRIPTION INSPECTION CONTROL ACCEPTANCE CERTIFYING VERIFYING
NO ACTIVITIES DOCUMENT CRITERIA DOCUMET
Contractor Owner Third Party

1 Preparation
1.1 Comply with
Material for Drainage System (U-Ditch, Contract Book 4.3.5 and MAR Document/Vendor Data
Specification, Method I/R SW -
Cover, and Box Culvert, ect.) Drawing or broschure, shop visit
B Statement, and Drawing
Comply with
Contract Book 4.4.2 and
1.2 Warehouse/Receiving Point at Site Specification, Drawong, Inspection Report I/R V -
Storage Instruction
List of Material

2 Earth Work

2.1 Setting out and positioning Approved Drawing Comply with Drawing ITP-C-0001-30 I/R V -

Contract Book 4.8.4.2.2 Comply with ITP-C-0001-10 and ITP-C-

2.2 Excavation I/R V -
and Drawing Specification 0001-11
Approved Method Comply with Method
2.3 Surface Trench Compaction ITP-C-0001-30 I/R V -
Statement Statement
Approved Method Comply with Method
2.4 Sand for leveling ITP-C-0001-30 I/R V -
Statement Statement
Approved Method Comply with Method
a) Compacting ITP-C-0001-30 I/R V -
Statement Statement

Rev.B 7 of 14
 ITP FOR INSTALLATION OF STORM WATER WORK
J910-DH02-P0ZEN-049003

INSPECTION AND TEST PLAN FOR INSTALLATION OF STORM WATER WORK

INSPECTION
REF PROCESS DESCRIPTION INSPECTION CONTROL CERTIFYING VERIFYING
ACCEPTANCE CRITERIA
NO ACTIVITIES DOCUMENT DOCUMET Contractor Owner Third Party

3 Erection / Installation
Approved Method
3.1 Setting out and positioning Comply with Method Statement ITP-C-0001-31 I/R V -
Statement
Approved Method
3.2 U-Ditch handling Comply with Method Statement ITP-C-0001-31 I/R V -
Statement
Approved Method
3.3 Alignment / Center Point Comply with Method Statement ITP-C-0001-31 I/R SW -
Statement
3.4 Cast-in-site Concrete for U-Ditch and Approved Method
Comply with Method Statement ITP-C-0001-31 I/R SW -
Box Culvert Joints Statement

4 Non-Destructive Testing
Approved Method
4.1 Surface cleanliness Comply with Method Statement ITP-C-0001-32 I/R V -
Statement
5 Joint Grouting
Approved Method
5.1 Surface cleanliness Comply with Method Statement ITP-C-0001-32 I/R V -
Statement
Approved Method
5.2 Grouting mixing and pouring Comply with Method Statement ITP-C-0001-32 I/R V -
Statement
6 Backfilling
Approved Method
6.1 Sand filling and Compacting Comply with Method Statement ITP-C-0001-33 I/R V -
Statement
Approved Method
6.2 Native Soil Filling and Compacting Comply with Method Statement ITP-C-0001-33 I/R V -
Statement

Rev.B 8 of 14
 ITP FOR INSTALLATION OF STORM WATER WORK
J910-DH02-P0ZEN-049003
IV. APPENDICES
APPENDIX 1
Form No. ITP-C-0001-10

INSPECTION FOR EXCAVATION

RECORD REPORT

Ref.Dwg / No.: ____________________ Report No. : _____________________

Area / Unit : ____________________ Date : _____________________
Location : ____________________ Subcon. Name : _____________________
Project : Jawa 9 & 10 (2x1000 MW) CFSPP

Inspection Result
No. Description Remarks
Accept Reject

1 The work site is cleared See attached DWG

All grass and weeds including roots are stripped and

2
removed
Excavation is performed to the lines grades and
3
slopes as drawing
Slope of all excavation are cut true and straight and
4
loos stone and boulders shall be removed in area
Excavation is made below the elevation level indicate
5
on the design drawing
Excavation is kept free of water at all times until
6
complete of construction or backfilling
7 Soil condition at the bottom of excavation

8 Protection work of excavated slope area for safety For Safety

9 Demolition or Protection of Existing/nearest Facility

10 Investigation of Existing under-ground Facilities

11 Condition of Compaction bottom surface

12 Safety regerding excavation works, confirmed

13 Quality of Cleaning

Result of Compaction Test after excavation,

14
confirmed (if necessary)
Note :

Submitted by __________Checked by __________ Inspected by __________Witnessed by __________________

Sub-con Sign/Date Construction Sign/Date QC Inspector Sign/Date IRT Inspector Sign/Date Sign/Date
(Rep.) (IRT)

Rev.B 9 of 14
 ITP FOR INSTALLATION OF STORM WATER WORK
J910-DH02-P0ZEN-049003
APPENDIX 2
Form No. ITP-C-0001-11

INSPECTION FOR BACKFILL

RECORD REPORT

Ref.Dwg / No.: ____________________ Report No. : _____________________

Area / Unit : ____________________ Date : _____________________
Location : ____________________ Subcon. Name : _____________________
Project : Jawa 9 & 10 (2x2000 MW) CFSPP

Inspection Result
No. Description Remarks
Accept Reject
1 Material for backfill are suitable and approved

2 No boulders and rock fragment are included

3 The thickness per lay is adequated

4 Adequated water sprayed when compacting

Samples for field density test were taken on test as

5
per specification
Test result of field density are above for fill or
6
required by specification or contract dwgs
7 Recompact all faulted area and test

8 Obtained max dry density according to specification

9 Protection of slope for safety

10 Quality of Cleaning before Backfill Accepted

Note :

Submitted by __________Checked by __________ Inspected by __________Witnessed by __________ ________

Sub-con Sign/Date Construction Sign/Date QC Inspector Sign/Date IRT Inspector Sign/Date Sign/Date
(Rep.) (IRT)

Rev.B 10 of 14
 ITP FOR INSTALLATION OF STORM WATER WORK
J910-DH02-P0ZEN-049003
APPENDIX 3
Form No. ITP-C-0001-30

INSPECTION FOR EARTH WORK

REPORT

Ref.Dwg / No. : ____________________________ Report No. : ________________________

Project : Jawa 9 & 10 (2x1000 MW) CFSPP Date : ________________________
Area / Unit : ____________________________ Subcon. Name : ________________________
Location : ____________________________

Inspection Result
No. Description Remarks
Accept Reject
1 Conformity to mute coordinated and elevation in the plan Drawing

2 Surface flatness ≤ 20mm

Trech width with a minimum 0.40 m
3 Truc Clearance for U-Ditch clearance on each side of the pipes at
trench.
4 Pouring Material

5 Sufficient compaction for each layer

Varies depending on the nature of the

6 Sand layer Thickness
material

Note :

Submitted by __________ Checked by __________ Inspected by __________ Witnessed by __________ ________

Sub-con Sign/Date Construction Sign/Date QC Inspector Sign/Date IRT Inspector Sign/Date Sign/Date
(Rep.) (IRT)

Rev.B 11 of 14
 ITP FOR INSTALLATION OF STORM WATER WORK
J910-DH02-P0ZEN-049003
APPENDIX 4
Form No. ITP-C-0001-31
INSPECTION FOR ERECTION / INSTALLATION
REPORT

Ref.Dwg / No. : ____________________________ Report No. : ________________________

Project : Jawa 9 & 10 (2x1000 MW) CFSPP Date : ________________________
Area / Unit : ____________________________ Subcon. Name : ________________________
Location : ____________________________

Inspection Result
No. Description Remarks
Accept Reject
1 Checklist for box culvert and u-ditch joint

a) Check for formwork

b) Check for reinforcement

c) Check for cast-in-site concrete

2 Conformity to mute coordinated and elevation in the plan

3 Joint and edge preparation

B 4 Orientation as per drawing

5 Slope as per drawing

Note :

Submitted by __________ Checked by __________ Inspected by __________ Witnessed by __________ ________

Sub-con Sign/Date Construction Sign/Date QC Inspector Sign/Date IRT Inspector Sign/Date Sign/Date
(Rep.) (IRT)

Rev.B 12 of 14
 ITP FOR INSTALLATION OF STORM WATER WORK
J910-DH02-P0ZEN-049003
APPENDIX 4
Form No. ITP-C-0001-32

INSPECTION FOR JOINT GROUTING REPORT

Ref.Dwg / No. : ____________________________ Report No. : ________________________

Project : Jawa 9 & 10 (2x1000 MW) CFSPP Date : ________________________
Area / Unit : ____________________________ Subcon. Name : ________________________
Location : ____________________________

Inspection Result
No. Description Remarks
Accept Reject
1 Preparing for equipment testing Refer to the mixture requirement As per Specification
a. CEMENT Sulphate resisting PORTLAND cement
b. SAND
c. ADMIXTURE SIKA LATEX
d. WATER
2 Surface cleanliness

3 Formwork

4 Mixing As per Specification

5 Pouring As per Specification

6 Finishing As per Specification

Note :

Submitted by __________ Checked by __________ Inspected by __________ Witnessed by __________ ________

Sub-con Sign/Date Construction Sign/Date QC Inspector Sign/Date IRT Inspector Sign/Date Sign/Date
(Rep.) (IRT)

Rev.B 13 of 14
 ITP FOR INSTALLATION OF STORM WATER WORK
J910-DH02-P0ZEN-049003
APPENDIX 4
Form No. ITP-C-0001-33

INSPECTION FOR BACKFILLING REPORT

Ref.Dwg / No. : ____________________________ Report No. : ________________________

Project : Jawa 9 & 10 (2x1000 MW) CFSPP Date : ________________________
Area / Unit : ____________________________ Subcon. Name : ________________________
Location : ____________________________

Inspection Result
No. Description Remarks
Accept Reject
1 Backfilling material as per specification As per Specification

2 Method of placing backfill material As per Specification

3 Compaction As per Specification

4 Line, grade, and elevation of finish

5 Tolerance by successive layers with the excavated materials deprived As per Specification

6 Identification of burried pipe line, or other objects As per Specification

Note :

Submitted by __________ Checked by __________ Inspected by __________ Witnessed by __________ ________

Sub-con Sign/Date Construction Sign/Date QC Inspector Sign/Date IRT Inspector Sign/Date Sign/Date
(Rep.) (IRT)

Rev.B 14 of 14