SERVICE ORDER FORM

COMPANY NAME : RSI DARUS SYIFA’ SURABAYA

JL. RAYA BENOWO NO.05 No 200-SC-F100-C
Address
SURABAYA Contract Ref. 1046/PPLI-LOA/XII-2019
PIC YESSY LANIA. F., AMd. KL Quo. Ref. 859/EJTS/MKT-XI/2019
Phone 0877-5105-0320 PO Ref.
Email Kesling.rsids@gmail.com

Dear PPLi,
I’d like to order of waste transportation and disposal of waste as described as below :
N
o Profile # Waste Description Code Qty Unit Unit Price (Rp.) Total Price (Rp.)
1  #30647 Used Lamp B107d 10 Kg
2  #46435 Aki Bekas A102d 1 Pcs
3 #46431 Catridge Bekas B321-4 0,5 Kg
4  #30642 Used Battery  A102d  15 kg    
5  #30646 Used Fixer & Developer  A339-1  40 Liter    
Expired Medicine (Non
6 #30645 A337-2 3 Kg
Kemo)
7 #30644 Sludge IPAL B337-2 3 Kg
8 #46433 Kain Majun Bekas B337-1 1 Kg
9 #46364 Kemasan Bekas B104d 2 Kg
10 #46430 Minyak Pelumas Bekas B105d 10 Liter
11 #35968 Rejected X-Ray Film Non B3 6 Kg
Transportation Charge
Grand Total (Excluding VAT10%) Rp.

Note :
1. Invoice based on actual received in PPLi Facility
2. Actual Packaging based on quotation reference
3. If any differences between Service Order and Quotation Letter, PPLi having authority to convert
as incoming without confirmation to the customer

Prepared and Send by

RSI DARUS SYIFA’ SURABAYA

Yessy Lania. F., AMd. KL

Ka. Unit Kesehatan Lingkungan