TGI-WP-45A-F03

Revision 03 : Printed 8 December 2014

PURCHASE REQUISITION FORM

1 PR Number : / /
cost center year number
2 Cost Center 42
3 Department RO1 14 Normal Category : (please put a tick√ )
Required Delivery Date Normal Direct for value < $ 29,999
4 Quotation for value $ 30,000 - < $ 74,999 *

5 AP4201/ Mandatory Requirements :

Project (Activity) Code GD4202/

TOR
GS4203
Account Code 5101217 OE (Approved by Authorized Personnel & in the Sealed Envelope)

6 510120402
7 Budgeted Yes Open and Close Tender for value $ 75,000 - Unlimited *

8 Approved Budget Mandatory Requirements :

9 Budget Balance TOR/ITB
OE (Approved by Authorized Personnel & in the Sealed Envelope)
(before this purchase)
PR for Open Tender advertisement

10 Delivery Location : Draft Material for Open Tender Advertisement

Form Close Tender if Close Tender Method
Direct Award :
Value US$ 1,00 - Unlimited
(User shall provide detail of delivery location, e.g.:
RO1- Jambi, Sakernan Panaran Station etc)
Mandatory Requirements :
* If ticked then complete & submit mandatory requirements with PR.

** If Unbudgeted Item, user shall prepare Additional Budget Approval

Form, submit and attach with PR

LOGISTIC DEPARTMENT WILL RETURN PR TO USER IMMEDIATELY IF ABOVE MANDATORY REQUIREMENTS ARE UNAVAILABLE OR INCOMPLETE

Unit Price Cost Estimate

11 No Item Description and Specification Quantity
IDR IDR
1 Kontrak payung pengadaan Office Supplies RO1 Jambi #REF! #REF!
1
(ATK, Alat Kebersihan & General Consumable)

VAT (PPN) 10% #REF!

TOTAL #REF!

Requested By Endorsed By Approved By

12
Signature

Name: Emi Haryaty Nengsih Yudi Yandri A Rashid Mukri

Position: OSS RO1 Manager RO1 Operation Director
Date:

Fill in by procurement officer with data below and recorded with actual receiving logistic stamp only.
13
Signature

Status Proceed / Need Clarification / Returned

 TGI-WP-451-F05

PT.Transportasi Gas Indonesia Formulir OE [Owner Estimate]

NAMA PEKERJAAN : LOKASI DEPARTEMEN : TANGGAL :

Kontrak Payung Pemeliharaan & Perawatan AC RO1

RO1 Jambi Regional Office 1 26 Februari 2021
(12 Bulan)

NO URAIAN VOLUME SATUAN HARGA SATUAN JUMLAH TOTAL

Kontrak Payung Pemeliharaan & Perawatan AC

I 1 Ls 684,495,000.00 684,495,000.00 684,495,000.00
RO1 (12 Bulan)

TOTAL 684,495,000.00
PPN 10 % 68,449,500.00
TOTAL + PPN 10 % 752,944,500.00

TERBILANG :
 PT.Transportasi Gas Indonesia Lampiran OE
NAMA PEKERJAAN : LOKASI : DEPARTEMEN : TANGGAL :

Kontrak Payung Pemeliharaan dan Perawatan AC RO1

JAMBI RO1 1-Mar-21
(12 Bulan)

NO URAIAN Jumlah Unit AC VOLUME SATUAN HARGA SATUAN JUMLAH TOTAL

I Fixed Cost (510120503)

OFFICE JAMBI
1 AC Model Split 1PK 11 4 Times 120,000.00 480,000.00 5,280,000.00
2 AC Model Split 1.5PK 4 4 Times 120,000.00 480,000.00 1,920,000.00
3 AC Model Split 2PK 9 4 Times 120,000.00 480,000.00 4,320,000.00
4 AC Model Cassete 2,5PK 11 4 Times 250,000.00 1,000,000.00 11,000,000.00
5 AC Model Cassete 3PK 2 4 Times 250,000.00 1,000,000.00 2,000,000.00
6 AC Model Cassete 3,5PK 2 4 Times 250,000.00 1,000,000.00 2,000,000.00

Sakernan Station
1 AC Model Split 1PK 26 4 Times 120,000.00 480,000.00 12,480,000.00
2 AC Model Split 2PK 28 4 Times 120,000.00 480,000.00 13,440,000.00
3 AC Model Split 2,5PK 3 4 Times 120,000.00 480,000.00 1,440,000.00
4 AC Model Cassete 3PK 4 4 Times 250,000.00 1,000,000.00 4,000,000.00
7 AC Model Split 1.5PK 11 4 Times 120,000.00 480,000.00 5,280,000.00
8 AC Model Split 3/4PK 1 4 Times 120,000.00 480,000.00 480,000.00
9 AC Model Standing 3PK 1 4 Times 250,000.00 1,000,000.00 1,000,000.00

Jabung Station
1 AC Model Split 1PK 63 4 Times 120,000.00 480,000.00 30,240,000.00
2 AC Model Split 1.5PK 6 4 Times 120,000.00 480,000.00 2,880,000.00
3 AC Model Split 2PK 9 4 Times 120,000.00 480,000.00 4,320,000.00
4 AC Model Split 2,5PK 2 4 Times 120,000.00 480,000.00 960,000.00
5 AC Model Ceiling 4PK 6 4 Times 250,000.00 1,000,000.00 6,000,000.00
6 AC Model Ceiling 5.5PK 7 4 Times 250,000.00 1,000,000.00 7,000,000.00
7 AC Model Ceiling 6.5PK 6 4 Times 250,000.00 1,000,000.00 6,000,000.00

Grissik Metering Station

1 AC Model Split 1PK 2 4 Times 120,000.00 480,000.00 960,000.00
2 AC Model Split 2PK 3 4 Times 120,000.00 480,000.00 1,440,000.00
3 AC Model Split 1.5PK 4 4 Times 120,000.00 480,000.00 1,920,000.00

Tempino Metering Station

1 AC Model Split 1 PK 5 4 Times 120,000.00 480,000.00 2,400,000.00
2 AC Model Split 2 PK 2 4 Times 120,000.00 480,000.00 960,000.00
3 AC Model Split 1.5PK 3 4 Times 120,000.00 480,000.00 1,440,000.00
4 AC Model Cassete 2,5PK 1 4 Times 250,000.00 1,000,000.00 1,000,000.00

Simpang Abadi Metering Station

1 AC Model Split 1PK 8 4 Times 120,000.00 480,000.00 3,840,000.00
2 AC Model Split 2 PK 1 4 Times 120,000.00 480,000.00 480,000.00
3 AC Model Split 2,5 PK 2 4 Times 120,000.00 480,000.00 960,000.00
4 AC Cassete 2.5 PK 1 4 Times 250,000.00 1,000,000.00 1,000,000.00

Total Fixed Cost I 138,440,000.00

II Transport & Accomodation (510120503)

1 Transportasi Grissik Metering Station 4 Times 750,000.00 3,000,000.00 3,000,000.00
2 Transportasi Tempino Metering Station 4 Times 750,000.00 3,000,000.00 3,000,000.00
3 Transportasi Sekernan Compressor Station 4 Times 750,000.00 3,000,000.00 3,000,000.00
4 Transportasi Jabung Compressor Station (Include Simpang Abadi Metering) 4 Times 750,000.00 3,000,000.00 3,000,000.00
5 Accomodation Grissik Metering Station 4 Times 1,500,000.00 6,000,000.00 6,000,000.00
6 Accomodation Tempino Metering Station 4 Times 1,500,000.00 6,000,000.00 6,000,000.00

Total Fixed Cost II 24,000,000.00

Total Fixed Cost I + II 162,440,000.00

III Reimbursement Jasa Service & Overhaul (510120503)

1 Service AC Split 3/4 s/d 1PK 25 Unit 650,000.00 16,250,000.00 16,250,000.00
2 Service AC Split 1,5 s/d 2 PK 4 Unit 650,000.00 2,600,000.00 2,600,000.00
3 Service AC Split 2,5 s/d 3 PK 8 Unit 650,000.00 5,200,000.00 5,200,000.00
4 Service AC Cassete & Ceilling3 s/d 5 PK 6 Unit 1,000,000.00 6,000,000.00 6,000,000.00
5 Service AC Cassete & Ceilling5 s/d 6,5 PK 4 Unit 1,000,000.00 4,000,000.00 4,000,000.00
6 Service AC standing 3 s/d 5 PK 2 Unit 1,000,000.00 2,000,000.00 2,000,000.00
7 Overhaul AC Split 3/4 s/d 1PK 12 Unit 850,000.00 10,200,000.00 10,200,000.00
8 Overhaul AC Split 1,5 s/d 2 PK 4 Unit 850,000.00 3,400,000.00 3,400,000.00
9 Overhaul AC Split 2,5 s/d 3 PK 8 Unit 850,000.00 6,800,000.00 6,800,000.00
10 Overhaul AC Cassete & Ceilling3 s/d 5 PK 6 Unit 1,500,000.00 9,000,000.00 9,000,000.00
11 Overhaul AC Cassete & Ceilling5 s/d 6,5 PK 4 Unit 1,500,000.00 6,000,000.00 6,000,000.00
12 Overhaul AC standing 3 s/d 5 PK 2 Unit 1,500,000.00 3,000,000.00 3,000,000.00

Total Reimbursement Jasa Service & Overhaul 74,450,000.00

IV Reimbursement Sparepart (510120503)

1 Finishing tape 5 ea 35,000.00 175,000.00 175,000.00
2 Tubing capilary 20 mtr 40,000.00 800,000.00 800,000.00
3 Bearing ball 608zz 5 ea 25,000.00 125,000.00 125,000.00
4 Bearing ball 6200zz 5 ea 25,000.00 125,000.00 125,000.00
5 Bearing ball 6202zz 5 ea 25,000.00 125,000.00 125,000.00
6 Bearing ball 6203zz 5 ea 25,000.00 125,000.00 125,000.00
 PT.Transportasi Gas Indonesia Lampiran OE
NAMA PEKERJAAN : LOKASI : DEPARTEMEN : TANGGAL :

Kontrak Payung Pemeliharaan dan Perawatan AC RO1

JAMBI RO1 1-Mar-21
(12 Bulan)

NO URAIAN Jumlah Unit AC VOLUME SATUAN HARGA SATUAN JUMLAH TOTAL

7 Thermistor 25 ea 150,000.00 3,750,000.00 3,750,000.00
8 Rubber mounting 10 ea 30,000.00 300,000.00 300,000.00
9 Filter dryer 10 ea 75,000.00 750,000.00 750,000.00
10 Access valve 10 ea 65,000.00 650,000.00 650,000.00
11 Capacitor fan 1,5 mF s/d 4mF 30 ea 50,000.00 1,500,000.00 1,500,000.00
12 Capacitor Compressor 20mF s/d 50mF 30 ea 75,000.00 2,250,000.00 2,250,000.00
13 Overload 1PK s/d 2,5PK 30 ea 50,000.00 1,500,000.00 1,500,000.00
14 Connector 1/4 s/d 5/8 20 ea 35,000.00 700,000.00 700,000.00
15 Kabel skun 2 s/d 8mm 30 ea 15,000.00 450,000.00 450,000.00
16 Kawat las perak 15 ea 25,000.00 375,000.00 375,000.00
17 Three Way valve 5 ea 75,000.00 375,000.00 375,000.00
18 Modul board indoor universal 17 ea 150,000.00 2,550,000.00 2,550,000.00
19 Sock elbow tembaga 20 ea 85,000.00 1,700,000.00 1,700,000.00
20 Capacitor starting 20 ea 350,000.00 7,000,000.00 7,000,000.00
21 Tubing copper 1/4 s/d 5/8 40 mtr 75,000.00 3,000,000.00 3,000,000.00
22 Freon R11 (Flushing) 10 tbg 850,000.00 8,500,000.00 8,500,000.00
23 Freon R22 20 tbg 1,550,000.00 31,000,000.00 31,000,000.00
24 Freon R417 10 tbg 1,850,000.00 18,500,000.00 18,500,000.00
25 Kompressor 1PK 5 ea 1,200,000.00 6,000,000.00 6,000,000.00
26 Kompressor 1,5 PK 5 ea 1,500,000.00 7,500,000.00 7,500,000.00
27 Kompressor 2 PK 5 ea 2,200,000.00 11,000,000.00 11,000,000.00
28 Kompressor 2,5 PK 5 ea 2,500,000.00 12,500,000.00 12,500,000.00
29 Kompressor 3 PK 5 ea 3,200,000.00 16,000,000.00 16,000,000.00
30 Kompressor 3,5 PK 4 ea 3,500,000.00 14,000,000.00 14,000,000.00
31 Kompressor 4 PK 4 ea 4,650,000.00 18,600,000.00 18,600,000.00
32 Kompressor 5.5 PK 4 ea 7,200,000.00 28,800,000.00 28,800,000.00
33 Kompressor 6.5 PK 4 ea 10,500,000.00 42,000,000.00 42,000,000.00
34 Oli Compressor Emkararate RL 68 H 10 can 85,000.00 850,000.00 850,000.00
35 Motor fan indoor 5 ea 350,000.00 1,750,000.00 1,750,000.00
36 Motor fan outoor 5 ea 350,000.00 1,750,000.00 1,750,000.00
37 Motor swing indoor 5 ea 150,000.00 750,000.00 750,000.00
38 Kontaktor 5 ea 350,000.00 1,750,000.00 1,750,000.00
39 Remote AC Original 18 ea 150,000.00 2,700,000.00 2,700,000.00
40 Pipa AC 1/4 3/8 25 mr 40,000.00 1,000,000.00 1,000,000.00
41 Pipa AC 3/8 5/8 25 mtr 60,000.00 1,500,000.00 1,500,000.00
42 Armaflex Pipa AC 3 inchi 22 ea 65,000.00 1,430,000.00 1,430,000.00
43 Oli Compressor Suniso 4GS 10 can 75,000.00 750,000.00 750,000.00
44 Modul board indoor outdoor 3 phase Daikin 5 ea 2,500,000.00 12,500,000.00 12,500,000.00
45 Modul board  Indoor dan outdoor  AC  3 phasa  York 1-6.5 pk 5 ea 4,500,000.00 22,500,000.00 22,500,000.00
46 Modul Receiver Remote York 1- 5PK 5 ea 850,000.00 4,250,000.00 4,250,000.00

Total Reimbursement Sparepart 296,205,000.00

Total fixed & Reimbursement 533,095,000.00

V Reimbursement Pengadaaan Unit Baru (5101215)

1 Pengadaan Unit AC Split 1PK Merk Daikin (include material dan pemasangan) 6 Unit 5,300,000.00 31,800,000.00 31,800,000.00
2 Pengadaan Unit AC Split 1,5PK Merk Daikin (include material & Pemasangan) 2 Unit 6,300,000.00 12,600,000.00 12,600,000.00
3 Pengadaan Unit AC Split 2PK Merk Daikin (include material dan pemasangan) 5 Unit 8,200,000.00 41,000,000.00 41,000,000.00
4 Pengadaan Unit AC Split 2,5PK Merk Daikin (include material dan pemasangan) 4 Unit 10,200,000.00 40,800,000.00 40,800,000.00

Total Reimburst Cost I 126,200,000.00

VI Reimbursement Pengadaaan Unit Baru (510120650)

1 Pengadaan Unit AC Split 1,5PK Merk Daikin (include material & Pemasangan) 4 Unit 6,300,000.00 25,200,000.00 25,200,000.00

Total Reimburst Cost II 25,200,000.00

Total II 684,495,000.00

TOTAL I + II 684,495,000.00

PPN 10 % 68,449,500.00
TOTAL I + II + PPN 10 % 752,944,500.00