Date Issued : 15 Oktober 2020 Work Performing :

Contract Title : Drilling Location Construction Services – Southern & Northern Area [ ] General
Contract No : SC1800303 [ ] Civil
Contractor : PT.PETRONESIA BENIMEL. [ ] Rehabilitation
[ ] Vegetation

Inspected by,
PHSS – PL NA & SA Department Contractor :
1. 1.
2. 2.

WORK LOCATION :
STATEMENT OF THE WORK :
SPK NO : 113/SBH/V/2020
Nilam Warehouse Pipe Yard
“Concreting Stagging at Nilam Pipe Yard”

Inspection detail :
a. Cut and Fill Type = Cu.M [ ] Accepted , [ ] Not Comment :

b. Concrete K-275 = Cu.M [ ] Accepted , [ ] Not Comment :

c. Lean Concrete K-125 = Cu.M [ ] Accepted , [ ] Not Comment :

d. Suplly and Installation Reinforcement Bars = Kg [ ] Accepted , [ ] Not Comment :

e. Demolish Concrete = Cu.M [ ] Accepted , [ ] Not Comment :

Completion of construction : Date : …………………………

Change Control Record : (any changes in cost and schedule must be recorded and must not be executed
without prior written approval from Pertamina Hulu Sanga Sanga).

Acceptance : Contractor :

Date : ………………………… Agus Subiandono

Project Manager

ANNEX - 1 OPERATION SUPPORT LOCATION CONSTRUCTION AND MISCELLANEOUS

(Brief description of comments inspection)
CIVIL WORK SERVICES
CONTRACT NO. SC1800303

PUNCH LIST & INSPECTION REPORT

ANNEX - 1
(Brief description of comments inspection)