PT SAKA ENERGI INDONESIA

The Energy, 11th – 12th Floor, SCBD Lot 11 A

Jl. Jenderal Sudirman Kav. 52-53
Jakarta 12190

Medical Fitness Certificate

Based on SAKA Fitness Medical Examination procedures and the Applicant’s health statement, examination
and evaluation, this certificate is to confirm that following person

Name : Herman Toijiba

Company : PT GROGOL SARANA TRANSJAYA

Position : Driver

Date of Birth : 42 tahun

Nationality : Indonesia

is:

☐ Fit

☒ Fit with Note :Kurangi makanan berlemak, kolesterol, dan gorengan, perbanyak makan sayur & buah.

☐ Temporary Unfit :

☐ Unfit

I certify that the above named employee has been assessed and is hereby determined allowed as the certain
task as below:

☒ Onshore Worker ☒ Shift Worker

☒ Offshore Worker ☒ Manual Handling
☐ Jakarta Office Worker ☐ Display Screen
☐ Work at Height ☐ Diver
☐ Confined Space or SCBA/respirator users ☐ Fire & Emergency Crew
☐ Professional Drivers ☐ Food handler
☐ Work in Extreme Temperature ☐ Onshore/offshore visitor
☐ Other professionals Click here to enter text.

This certificate is valid:12-Oct-20 Until: 12-Oct-21

Date: 10-Jun-21

Assessed by,

dr. Rizky Umar Y. dr. Titis Mariyamah,MKK,SpOK

Site Doctor Chief Medical Officer

Doc. No. FORM-OH/IH-SEI-HSE-006