OVER TIME REQUEST FORM

To : PT. Chevron Pacific Indonesia Date : 1 1 0 1 2 1

D D M M Y Y
Attn : CPI FIC/CPM
From : PT. Singgar Mulia & Brown Root Page : 0 1 o f 0 1
Dept : Construction

Dear Sir,
We would like to request your approval for our employee(s) to work overtime O/T as per Work Authorization / EPF below:
WORKING HOURS TOTAL
NO NAME OF EMPLOYEE BADGE DATE of O/T JOB CODE/NO. PT DESCRIPTION
FROM UNTIL HOURS

SR 1288861/ WI 13316 Monitoring and Inspection for surface preparation, Visual, DFT and HDT of
1 Heri Febriyanto 418674 11-Jan-21 16:00 17:00 1 Sleeve installation 24" & 26" at bangko KRS painting application for Sleeve installation 24" & 26" at bangko northern (337
northern (337 Pairs) 2020 Pairs) 2020

SR 1288861/ WI 13316 Monitoring and Inspection for surface preparation, Visual, DFT and HDT of
2 Heri Febriyanto 418674 12-Jan-21 16:00 17:00 1 Sleeve installation 24" & 26" at bangko KRS painting application for Sleeve installation 24" & 26" at bangko northern (337
northern (337 Pairs) 2020 Pairs) 2020

SR 1288861/ WI 13316 Monitoring and Inspection for surface preparation, Visual, DFT and HDT of
3 Heri Febriyanto 418674 13-Jan-21 16:00 17:00 1 Sleeve installation 24" & 26" at bangko KRS painting application for Sleeve installation 24" & 26" at bangko northern (337
northern (337 Pairs) 2020 Pairs) 2020

SR 1288861/ WI 13316 Monitoring and Inspection for surface preparation, Visual, DFT and HDT of
4 Heri Febriyanto 418674 14-Jan-21 16:00 17:00 1 Sleeve installation 24" & 26" at bangko KRS painting application for Sleeve installation 24" & 26" at bangko northern (337
northern (337 Pairs) 2020 Pairs) 2020

SR 1288862/ WI 13317 Monitoring and Inspection for surface preparation, Visual, DFT and HDT of
5 Heri Febriyanto 418674 15-Jan-21 16:00 17:30 1 Sleeve installation 26" at bangko WAC painting application for Sleeve installation 26" at bangko northern (330 Pairs)
northern (330 Pairs) 2020 2020

Request By, Approved By,

Employee/Lead/Supervisor/Dept. Manager CPI User

Heri Febriyanto #418674

Coating Inspector CPI Facility Representative
 KRS 1288861

SR 1287408/ WI 11116 WAC 1298862

SR 1287477/ WI 11239