P8/KI-D1/05.

0/XII/2019/005010
Description of products :
No. Common Name Scientific Name Quantity Unit
1 UDANG LIPAN / SQUILLA ORATOSQUILLA NEPA 840.00 HDS

TOTAL 840.00 HDS

1. Consignor / Pengirim Barang 2. Competent Authority

Name / Nama : REGIONAL FISH QUARANTINE AND INSPECTION
CV. CHEERA KING SEAFOOD AGENCY (RFQIA) MEDAN I
Address / Alamat :
JALAN KOTA BARU II 082166022288

3. Consignee / Penerima Barang

Name / Nama :
S.G.S IMPORT EXPORT CO,LTD
Address / Alamat :
NO : 1 LADKABANG ROAD, DISTRICT : LADKABANG, SUB PROVINCE : LADKABANG, PROVINCE : BANGKOK, POST CODE : 10520

4. Producing establishment / farm / Pabrik Pengolahan / budidaya Aquaculture establishment / Unit Usaha Pembudidayaan Ikan (UUPI) √ Others / Lainnya
Name / Nama : No. UPI / Establishment ID Number :

Address (Detailed) / Alamat Lengkap :

5. Country and region of origin / Negara dan daerah asal : 6. Source / Sumber :
THE REPUBLIC OF INDONESIA, NORTH SUMATRA Farm - Raised / Budidaya √ Wild - Caught / Tangkap

7. Port of shipment / Pelabuhan pengeluaran: 8. Means of transport / Alat transportasi :

BANDARA INTL. KUALA NAMU - MEDAN, MEDAN, INDONESIA √ Aeroplane / Angkutan udara Ship / Angkutan laut Road vehicle / Angkutan darat

9. Description of commodity / Deskripsi komoditas : 10. Temperature of the commodity / Temperatur komoditas :
UDANG LIPAN / SQUILLA
√ Ambient (live) / Frozen / beku Chilled / dingin
ruang (hidup)

11. Commodities intended for uses as / komoditas diperuntukan sebagai : 12. Total number of packages, associated Batch number and number of
packages per batch / Jumlah kemasan total terkait nomor dan kemasan :
√ Human consumption / konsumsi manusia
12 BX
Culture / breeding (broodstock, eggs, gamates) / budidaya
Ornamental / ikan hias
Research & Isvestigation / Penelitian dan pemeriksaan
Aquatic animal feed / baits / pangan / umpan pancing
Non edible (fish skin, shell, bones, etc) *(information on batch see attachment if insufficient)

13. Type of packaging / Jenis kemasan : 14. Total quantity (kg) / Jumlah total (kg) :
BX 336.00 KGM

15. Identification of container / seal number / Identifikasi Kontainer / nomor seal : 16. Port of destination / Pelabuhan tujuan :
DON MUEANG, THAILAND

17. Identification of transport / Identitas alat transport : 18. Date of Departure / Tanggal pengiriman:
Name of Transportation / Nama Alat Angkut : AIRASIA December 10, 2019
Voyage Number / Nomor penerbangan : QZ154
19. Testing laboratory / Laboratorium penguji: Address / Alamat:
REGIONAL FISH QUARANTINE AND INSPECTION AGENCY (RFQIA) MEDAN I Jl. Karantina Ikan Desa Araskabu, Kec. Beringin, Kab. Deli serdang, Medan, Indonesia
LABORATORY

Approving officer name / Penanggungjawab laboratorium :

Mulana Sari Saragih,S.Si,M.Si
Testing report number / Nomor laporan hasil uji:
E/P1.5/05.0/XII/2019/002563 Signature / Tanda tangan
Ref. Number : P8/KI-D1/05.0/XII/2019/005010

Attestation

The undersigned Certifying Official certifies that the product(s) / Pejabat penandatangan sertifikat di bawah ini menyatakan bahwa produk :
Fin Fish / Ikan bersirip √ Mollusca / Moluska Crustacea / Krustasea Fishery Products / Produk perikanan Others / Lainnya
described above satisfy(s) the following requirements / yang diuraikan di atas memenuhi persyaratan berikut

√ a. Commodity from population *) described above have been processed, inspected and graded in (an) establishment(s) that has been approved by and under control of the
Competent Authority / Produk tersebut di atas telah diproses, diinspeksi dan dinilai dalam kondisi yang telah disetujui oleh dan di bawah kendali Otoritas Kompeten

√ b. have been handled, prepared or processed, identified, stored and transported under a competent HACCP and sanitary programme consistently implemented and in accordance with
the requirements laid down in Codex Code of Practice for Fish and Fishery Products (CAC/RCP 52-2003) / telah ditangani, disiapkan atau diproses, diidentifikasi, disimpan dan
ditransportasikan sesuai persyaratan sanitasi dan HACCP yang diterapkan secara konsisten dan sesuai dengan persyaratan yang ditetapkan Codex Code of Practice for Fish
and Fishery Products (CAC / RCP 52-2003)
√ c. Commodity from population *) has been found to be free of disease based on sampling and testing method recognized by the World Organisation for Animal Health (OIE) for
demonstrating absence of disease and inspected according to the appropiate procedures and subsequently found, at the time of inspection / Produk /dari setiap batch pasca
pengolahan bebas dari penyakit berdasarkan pengambilan sampel dan metode pengujian yang diakui oleh World Organisation for Animal Health (OIE) dan pada saat
pemeriksaan:

√ to be free from diseases / bebas dari penyakit: WSSV

√ to show no visible/ clinical signs of diseases / tidak menunjukkan gejala penyakit secara visual / klinis: All infectious diseases

d. For non edible products have been handled, prepared or processed, stored, transported based on biosecurity principles / produk non pangan telah ditangani, disiapkan atau
diproses, disimpan, ditransportasikan berdasarkan prinsip biosekuriti

Additional information / Information tambahan:

23. CERTIFIED DETAILS / Detail Penerbit Sertifikat Issued at Medan, On December 09, 2019
Name / Nama : RIO BENNI S.Pi Certifiying Body : REGIONAL FISH QUARANTINE AND INSPECTION
Position / Posisi : Inspector AGENCY (RFQIA) MEDAN I
Issued at / Lokasi : Indonesia, Medan
Phone / Telepon : 061-42079682 Stamp / Stampel

Fax / Faksimili : 061-42079683

E-mail / Surat Elektronik : bkipolonia@yahoo.co.id
Address / Alamat : Jl. Karantina Ikan Desa Araskabu, Kec. Beringin, Kab. Deli
serdang, Medan, Indonesia
Signature / Tanda tangan RIO BENNI S.Pi
Name of Official / Inspector