Esr Jaw-Ji-Trk-4072 Numpakces

DOCUMENT COMPLETION CHECK LIST
for TSSR DESIGN REVIEW
Site Name : NUMPAKCES TRENGGALEK
Indosat Site ID :
CLIENT SITE ID : JAW-JI-TRK-4072
SITE COORDINATE : LAT: '-8,179472 LONG: 111,5959
SITE ADDRESS : Klangsur, Dongko, Kabupaten Trenggalek, Jawa Timur 66363, Indonesia
No Description OK NOK NA
1 Cover
2 Berita Acara Survey Form
3 List of Existing Antenna & Proposed Antenna
4 RBS Foundation Layout Drawing
5 Antenna Placement Layout Drawing
6 Foto of RBS Placement Plan
7 Foto of Antenna Placement Plan
…………… , …………………
Submitted by, Checked by,
PT. HUAWEI TECH INVESTMENT PT. INDOSAT
(-----------------------------------------------) (------------------------------------------------)
PROPOSED SITE COLLOCATION SUMMARY
FOR
COLO SHARED INFRASTRUCTURE
SITE NAME ISAT

NUMPAKCES TRENGGALEK
INDOSAT SITE ID
CLIENT SITE ID JAW-JI-TRK-4072
SITE COORDINATE LAT: -8,179472 LONG: 111,5959
SITE ADDRESS Klangsur, Dongko, Kabupaten Trenggalek, Jawa Timur 66363, Indonesia
Other Licensed Operator
Client Name PT. XL AXIATA, TBK
Prepared by PT. HUAWEI TECH INVESTMENT
Survey date 11-Dec-20

RF
List of Existing Antenna & Proposed Antenna

for TSSR DESIGN REVIEW
Site Name : NUMPAKCES TRENGGALEK

Indosat Site ID :
CLIENT SITE ID : JAW-JI-TRK-4072
I. Existing Antennas
Size / Diameter Qty Height Azimuth

Description Remarks
(m) (pcs) (m) (°)
MW 1.8 1 49 180 XL
MW 0.6 1 23 250 XL
II. Proposed Antennas
Size Weight Inc Qty Feeder

Height Indosat
Description Type /Diameter Mounting (pc Azimuth (°) Diameter
(m) Recommendation
(m) Bracket (Kg) s) (inch)
46
RF 3 60/150/270
RRU 6 46
MW
III. Proposed BTS

BTS Type Dimension (m2) Indosat Recommandation
Outdoor / Indoor 5x1
…………… , …………………
Prepared by, Approved by,

PT. HUAWEI TECH INVESTMENT PT. INDOSAT
(-----------------------------------------------) (------------------------------------------------)
PHOTOGRAPH DOCUMENTARY
Site No. : Project : Mini CME XL Project
Site Name : Location :
Visit Date : 11-Dec-20
Prepared by : PT. HUAWEI TECH INVESTMENT
Surveyor : PT. PERSONEL ALIH DAYA
Proposed RBS
Site No. : JAW-JI-TRK-4072 Project : Mini CME XL Project
Site Name : Location :
Proposed Antenna
Proposed Antenna
REQUEST FOR APPROVAL
(Tower Rental Project)
Date :
SITE ID SITE INFO PROVIDE REMARK
SITE ID XL: JAW-JI-TRK-4072 RNP
SITE ID ISAT : 0 RF : 46m, azimuth :
SITE NAME XL : NUMPAKCES TRENGGALEK Location Photograph
TNP
Address: NE HEIGHT NE DIAMETER AZIMUTH FE SITE ID
FE HEIGHT FE DIAMETER AZIMUTH FREQUENCY

Klangsur, Dongko, Kabupaten Trenggalek, Jawa Timur 66363, Indonesia
Search Site Report
CIVIL 03/09/20
Foundation 5m x1 m
Tower Height : 50 m
Tower Type : Greenfield Power : 09/09/20
LOI PLN 13.2 Kva
Candidate Proposed Coordinate
LATITUDE : 0
LONGITUDE : 112.246437 Property Document
BSS 03/09/20
Prepared by,
PT. HUAWEI TECH INVESTMENT
NAME :
Date :
CHECKLIST APPROVAL PROPOSAL
Date Of Issue : PERANGKAT JUMLAH SPESIFIKASI DATA TEKNIS REMARKS

Tower Owner : XL-AXIATA Ketinggian
Site ID Opetaror : 0 Azimuth 1 (°)
Site Name Operator : NUMPAKCES TRENGGALEK ANTENNA Azimuth 2 (°)
RND
Site ID XL : JAW-JI-TRK-4072 Azimuth 3 (°)
Site Nama XL : Feeder (") OPTIC
Site Address : Klangsur, Dongko, Kabupaten Trenggalek, RBS TYPE INDOOR /OUTFOOR OUTDOOR
Jawa Timur 66363, Indonesia
PLN CAPACITY
POWER
PLN + GENSET
CDC
Ukuran Shelter M
SHELTER INDOOR
Ukuran Pondasi M
Actual Coordinat Survey Ukuran Shelter M
SHELTER OUTDOOR
Longitude : 112.246437 Ukuran Pondasi M
CIVIL
Latitude : -8,179472 TOWER CAPACITY %
FAR END #1 (Site ID/Site Name) : …………………………………………………………………………………………..
Ketinggian 0
Diameter M
ANTENNA 1 Azimuth (°)
Frekuensi GHZ
Far End Site ID / Name
TRANSMISI Ketinggian MAGL
Diameter M
ANTENNA 2 Azimuth (°)
Frekuensi GHZ
Far End Site ID / Name
SITAC PIC RND POWER CIVIL TRANSMISSI
Name: Name: Name : Name :

Date : Date : Date : Date : Date :
PREPARED by : HUAWEI TECH INVESTMENT
ENGINEERING SURVEY REPORT
Prepared by : Project :
PT.Huawei Tech Investment Tower Rental New Build / Collocation Existing
Document response / approved : Checked : Doc No : Revision : ………

(by provider)
Site No. : JAW-JI-TRK-4072
Site Name :
Visit Date : December 11, 2020
I. GENERAL INFORMATION
Area : JAWA TIMUR
Site Address :
Klangsur, Dongko, Kabupaten Trenggalek, Jawa Timur 66363, Indonesia
Contact Person :
Phone Number :
Contact Person Address :
Access to site : ✘ Available Not Available Need a new additional access

Remarks : detail information (car entry or by walking or need ladder etc)
Access 24 hours/day : ✘ Yes Not identify hours : ………….to……………..
II. GEOGRAPHIC INFORMATION

NOM Coodinates LATITUDE : Long :
GPS Coordinates LATITUDE : 0 Long : 112.246437
✘
Map Datum : WGS 84
✘ Mark position on map ✘ A4 sketch from above
III. PHOTOGRAPH DOCUMENTARY

Photos taken ✘ GPS Photo 1 photos
✘ Surroundings tower (google maps) 1 captures & sketch
✘ 360 degree panorama, each 30 degree 12 photos
✘ Proposed site location 4 photos
✘ Site Access Maximum photos
✘ Obstacle objects - photos
Taken on ✘
Ground Exist. Tower Building Tree
Altitude 45 M.a.s.l (meter above sea level)

✘ Mark position on map ✘
A4 sketch from above
Page 1 of 7

(by provider)
IV. RADIO FREQUENCY ( RF ) DATA

RBS Antenna Height :
✘
RBS Antenna Direction : ✘ ✘
Surroundings :
OBSTACLE Direction (deg) Distance (m) Height (m)
ANTENNA TYPE V-POL X-POL
✘
RBS TYPE INDOOR OUTDOOR MODEL :
Note : Diisi oleh PIC RND XL berdasarkan info & data di SSR
IN GRID /OFF GRID : 0.00 M at ### 0
OTHER COMMENTS:
Note : Diisi oleh PIC RND XL
RF RECOMMENDATION : ✘
OK NOT OK
PIC BSS-RND Name :
Page 2 of 7

(by provider)
V. TRANSMISSION DATA
Prop.MW Antenna Height : ……...…. M
Diameter : ………….M Azimuth 21.55 …………..
SITE FACING PLAN (FE)
FACING SITES SITE ADDRESS LATITUDE LONGITUDE ALTITUDE (masl)

312A349G
TRM CONFIGURATION DATA (*)
FACING SITES DISTANCE (km) BEARING (degree) ANTENNA HEIGHT (m) DIAMETER (M)
(*) Diisi hanya untuk Project XL Own Build / oleh Vendor Sitac Regular
SURROUNDINGS (Including Panoramic Photograph)
OBSTACLE DIRECTION (deg) DISTANCE (km) HEIGHT (m)
OTHER COMMENTS :
TRM RECOMMENDATION : OK NOT OK

PIC TRM Name :
page 3 of 7

(by provider)
VI. CIVIL INFRASTRUCTURES DATA
SITE CATEGORY : ✘ Green Field Roof Top ✘

Existing
GREEN FIELD
General Topographi : ✘
Flat Swamp Slope Hilty
Soil General Classification : ✘

Normal Rocky Sandy Clay / Muld
Obstruction ✘
No Trees Building ……………..
Site Improvement required : ✘

Clearing Stripping Cut / Fill Demolist existing
ACCESS TO SITE
Distance from public road : 20 Meter Width : 3 Meter
Type of pavement : Hotmix Asphalt ✘ Concrete Paving Block
Macadam Aggregate ✘ Soil ……………..
Length of private access : Meter Width : Meter
Type of pavement : Hotmix Asphalt ✘ Concrete Paving Block
Macadam Aggregate Soil ……………..

Improvement required : Bridge Pavement ✘ Other (Manual Hauling)
PROPOSED AREA TO BE ACQUIRED (GREEN FIELD) (*) ###

Lot Size : Prop. Pondation : 5Mx1M
Access To Site : 20 X 3 = 60 Meter (Distance from public road) ###
ROOF TOP - BUILDING STRUCTURE

Height Structure Type : Stories ………………… number
Roof Top ………………… meter
Penthose ………………… meter
Other ………………… meter
Old of Building : 0 Years
Building Structure Type : Reinforcr Concrete Steel Other
Building Using : Home Office Mall/Shop School/hospital
Potential Obstacle When N/A

:
Construction or Operation Available
page 4 of 7

(by provider)
ROOF TOP ACCESS

Access for Crane : Yes No
Stairway available : Yes No
- Dimension : m wide X m height
Passenger Lift : Yes No
- Capacity : ………… persons, from ……….. Trough ……………Floor
Material Lift : Yes No
- Capacity : ………… kg, from ……………. Trough ……………Floor
- Dimension : ………… m wide …………… m height
Ladder Yes No
- Dimension m Wide m Depth m Height
Potential Obstacle for Material

:
Equipment delivery
ADDITIONAL SUPPORTING STRUCTURE REQUIRED (*)

Beam : …………………. m length
Access Ladder : …………………. m length ……………. m wide Other : ………………..

GROUNDING and LIGHTNING PROTECTION SYSTEM in BUILDING

Is grounding system available ? : No ✘ Yes Type and size :
Is it possible to use ? : No ✘
Yes
Is lightning protect available ? : No ✘ Yes Type and size :
Is it possible to use ? : No ✘
Yes
SHAFT and CABLE ROUTING

Is cable shaft available ? : ✘ Yes ✘ No
Routing cables/feeder : Tray Clamped Other : …………………
: length : …………………. M (including Routing Drawing)
PROPOSED AREA TO BE ACQUIRED (ROOF TOP) (*)

Lot Size : Rent Area : ..………….. Meter X ……………. Meter = ……….. Meter²
Access To Site : …………… Meter X ……………. Meter = ……….. Meter²
page 5 of 7

(by provider)
TOWER DATA
Tower Height : 50 M ✘
From Ground Level From Roop Top Level
Tower Type : ✘
Self Supporting Tower Monopole/Single Pole
: Guyed Tower Three Camouflage
LEASING & PERMIT INFORMATION (*)
Lease Space : L 5 Meter X W 1 Meter X H…………… Estimated Rent ?
Can the site be Leased ? : ✘ Yes No
Can the site be Permitted ? : ✘

Yes No
OTHER COMMENTS
Propose BTS for flood area

Flood Level +80 cm
Need Manual Haulling for material, due to access limitless
CIVIL RECOMMENDATION : OK NOT OK

PIC Civil Eng Name :
page 6 of 7

(by provider)
VII. POWER & ELECTRICITY
POWER SOURCE
Power Availability (PLN) For XL ✘
Available Not Available Capacity : 6.6 KVA
Distance From Existing PLN Pole : 5 meter nearest Traffo 150 m
Provided by building / PLN, Capacity : ... KVA ( FOR ROOF TOP SITE)
Additional facilities required (*) : ✘

Poles Cable Transformer Other
OTHER COMMENTS:
POWER RECOMMENDATION : OK NOT OK

PIC Power Eng Name :
page 7 of 7
VII. ATTACHMENT
DOCUMENT INDICATION
✘
Photo GPS Photos
✘
Surroundings tower (radius 200 m) Google maps & Sketch
✘
360 degree panorama, each 30 degree Photos
✘
Site situation, access, existing facilities, etc Photos & Sketch
✘
Obstacle objects & near field obstruction Photos
✘
Existing facing sites Photos & Sketch
✘
Proposed site & Area Photos & Sketch
✘
Actual centerline, North on sketch Sketch
✘
Location and size of column and beam, existing and additional Photos & Sketch
✘
Proposed Location and Shelter, Tower, AC, Power meter, etc Photos & Sketch
✘
Proposed routing of cables (co-axial, power, grounding, lightening conductor) Photos & Sketch
✘
Antenna type, location, level and direction, present, future Sketch
✘
Site Outline Drawing Hard Copy
Klangsur, Dongko, Kabupaten
Site Name : Location : Trenggalek, Jawa Timur 66363,
NUMPAKCES TRENGGALEK Indonesia
GPS
Jl. Kuin Cerucuk 43, Kuin Cerucuk, Kec.

Site Name : Location : Banjarmasin Bar., Kota Banjarmasin,
NUMPAKCES TRENGGALEK Kalimantan Selatan 70127, Indonesia

Surveyor : PT. PERSONEL ALIH DAY
GPS Coordinates : Longitude :

Nominal : Latitude : -8,179472 Longitude :
Candidate : Latitude : -8,179472 111,5959
Distance candidate to nominal: 0 M 111,5959
Jl. Kuin Cerucuk 43, Kuin Cerucuk, Kec.
Banjarmasin Bar., Kota Banjarmasin,
Kalimantan Selatan 70127, Indonesia
PT. HUAWEI TECH INVESTMENT

Panoramic 0o Panoramic 30o






Panoramic 100o
Panoramic 270o
Panoramic 330o
Panoramic 330o
Tampak Atas Bagian Depan Site Tampak Atas Bagian Belakang Site


Tampak Atas Bagian Kiri Site Tampak Atas Bagian Kanan Site


SITE ACCESS TO SITE
SITE ACCESS TO SITE
* Need add manual hauling for material due to access limitless, ± 35 meter
SITE ACCESS TO SITE

POLE PLN
TRAFO PLN
SITE SITUATION 1
SITE SITUATION 2
As to As (tower width leg to leg) - process
anchor measurement
steel baseplate measurement thickness

one of leg member measurement - thickness
As to As (tower width leg to leg) - detail
steel baseplate measurement width
one of leg member measurement - width

Esr Jaw-Ji-Trk-4072 Numpakces

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DOCUMENT COMPLETION CHECK LIST

for TSSR DESIGN REVIEW

Site Name : NUMPAKCES TRENGGALEK

CLIENT SITE ID : JAW-JI-TRK-4072

SITE COORDINATE : LAT: '-8,179472 LONG: 111,5959

2 Berita Acara Survey Form

3 List of Existing Antenna & Proposed Antenna

4 RBS Foundation Layout Drawing

5 Antenna Placement Layout Drawing

6 Foto of RBS Placement Plan

7 Foto of Antenna Placement Plan

Submitted by, Checked by,

PT. HUAWEI TECH INVESTMENT PT. INDOSAT

SITE NAME ISAT

CLIENT SITE ID JAW-JI-TRK-4072

SITE COORDINATE LAT: -8,179472 LONG: 111,5959

Other Licensed Operator

Client Name PT. XL AXIATA, TBK

Prepared by PT. HUAWEI TECH INVESTMENT

Survey date 11-Dec-20

List of Existing Antenna & Proposed Antenna

Site Name : NUMPAKCES TRENGGALEK

Size / Diameter Qty Height Azimuth

II. Proposed Antennas

Size Weight Inc Qty Feeder

III. Proposed BTS

Prepared by, Approved by,

FE HEIGHT FE DIAMETER AZIMUTH FREQUENCY

Date Of Issue : PERANGKAT JUMLAH SPESIFIKASI DATA TEKNIS REMARKS

SITAC PIC RND POWER CIVIL TRANSMISSI

Name: Name: Name : Name :

Document response / approved : Checked : Doc No : Revision : ………

Site No. : JAW-JI-TRK-4072

Contact Person Address :

Access to site : ✘ Available Not Available Need a new additional access

Access 24 hours/day : ✘ Yes Not identify hours : ………….to……………..

II. GEOGRAPHIC INFORMATION

GPS Coordinates LATITUDE : 0 Long : 112.246437

III. PHOTOGRAPH DOCUMENTARY

Altitude 45 M.a.s.l (meter above sea level)

Document response / approved : Checked : Doc No : Revision : ………

IV. RADIO FREQUENCY ( RF ) DATA

OBSTACLE Direction (deg) Distance (m) Height (m)

ANTENNA TYPE V-POL X-POL

IN GRID /OFF GRID : 0.00 M at ### 0

Note : Diisi oleh PIC RND XL

PIC BSS-RND Name :

Document response / approved : Checked : Doc No : Revision : ………

SITE FACING PLAN (FE)

FACING SITES SITE ADDRESS LATITUDE LONGITUDE ALTITUDE (masl)

TRM CONFIGURATION DATA (*)

SURROUNDINGS (Including Panoramic Photograph)

OBSTACLE DIRECTION (deg) DISTANCE (km) HEIGHT (m)

TRM RECOMMENDATION : OK NOT OK

Document response / approved : Checked : Doc No : Revision : ………

VI. CIVIL INFRASTRUCTURES DATA

SITE CATEGORY : ✘ Green Field Roof Top ✘

Soil General Classification : ✘

Site Improvement required : ✘

Macadam Aggregate ✘ Soil ……………..

Length of private access : Meter Width : Meter

Type of pavement : Hotmix Asphalt ✘ Concrete Paving Block

Macadam Aggregate Soil ……………..