PEMBANGUNAN DERMAGA III

FUEL TERMINAL BAUBAU

DOCUMENT TRANSMITTAL
To : Date :
Attn. : Transmittal No. :

Cc :
From :
Subject :

Transmitted for : Review Information

Approval Record

No. Document No. Title Status Remarks

Submitted by, :

Date

Receipt by, :

Date
 REQUEST FOR INSPECTION (RFI)

Project : Pembangunan Dermaga III FT Baubau Location :

Owner : PT. Pertamina (Persero) RFI No. :
Attn : Date :
Ref. Dwg : Time :

Subject : Inspection for Rebar Installation of..........

Scale Priority : Urgent Impact Execution Urgent Others
: Immediate Immediate
Normal Normal
Subject Description :
.....................................................................................................................................................................
.....................................................................................................................................................................

Subject Attention :
.....................................................................................................................................................................
.....................................................................................................................................................................

Request by, Acknowledge by,

Aris Styawan P. Imam Sodiq

Answer Disposition :
.....................................................................................................................................................................
.....................................................................................................................................................................

Answered by, Approved by,

Postion : Postion :
Date : Date :
 PENGEMBANGAN TERMINAL BBM
BAUBAU
PEMBANGUNAN SARANA
KSO NINDYA-BBB
PENYALURAN

CHECKLIST OF CONCRETE POURING PERMIT

Client : PT. Pertamina (Persero) Request Date :

Project Title : Pembangunan sarana penyaluran Reff. No. :

A. Area
B. Name of building
C. Position of pouring
D. Date of pouring
E. Volume of concrete : ...................................................................................................................
F. Mixing Process
G. Concrete Spec.
H. Inspection Result
: ...................................................................................................................
: ...................................................................................................................
: ...................................................................................................................
: ...................................................................................................................
: Wet Mixing Dry Mixing Site Mixing
: Type of cement : ......................................................
Strenght required : ......................................................
Slump required : ......................................................

Check Result
No. Description Insp. I Insp. II
Dated OK Not OK Dated OK Not OK
1. Formwork
- Dimension
- Alignment
- Tightness
- Strength
- Form oil
- Plumbness
- Cleanliness
2. Rebarwork
- Size
- Spacing
- Splicing
- Covers
3. Anchor bolt
- Type
- Size
- Projection
- Alignment
4. Embedded plate
- Type
- Size
- Projection
- Alignment
5. Opening
- Dimension
- Projection
- Alignment

CHECKED AND APPROVED BY, CHECKED AND REVIEWED BY,

OWNER KSO NK-BBB
PT. PERTAMINA (Persero) MK Project Manager Site Manager QS

Name : Name : Name : Name : Name :

Date : Date : Date : Date : Date :
 PENGEMBANGAN TERMINAL BBM
BAUBAU
PEMBANGUNAN SARANA KSO NINDYA-BBB
PENYALURAN

CHECKLIST FORM REBAR INSTALLING

Date : ................................
Location : ................................
Subcject : ................................
Wire
Quantity & Dimension Distance Lap Length Concrete Cover Others (by visual)
Concrete
Type / Surface
Dia. Design Actual Design Actual Tolerance Design Actual Tolerance Design Actual Tolerance Cleaning Rigidity
Section OK / OK / OK / OK / OK / NOT
NOT OK NOT OK NOT OK NOT OK OK OK/NOT OK/NOT
(mm) (pcs) (pcs) (mm) (mm) (mm) (mm) (mm) (mm) (mm) (mm) (mm)
OK OK

Notes :

CHECKED AND APPROVED BY, CHECKED & REVIEWED BY,

OWNER KSO. NK-BBB
PT. PERTAMINA (Persero) MK PROJECT MANAGER SITE MANAGER QS

Name : Name : Name : Name : Name :

Date : Date : Date : Date : Date :
 PEMBANGUNAN DERMAGA III
FUEL TERMINAL BAUBAU

CHECKLIST FORM FORMWORK INSTALLING

Date : ................................
Location : ................................
Subcject : ................................
Check
Check Support
Dimension Top Elevation Chamfer Others
Distance
Type / (visual)
Section Design Actual Form Oil Stability
Design Tolerance Actual Comply / Not
OK Not OK OK Not OK
(elv.) (mm) (elv.) Comply
Length Width Height Dia. Length Width Height Dia. Not Not
(mm) (mm) (mm) (mm) (mm) (mm) (mm) (mm) OK OK OK OK

Notes :
CHECKED AND APPROVED BY, CHECKED & REVIEWED BY,
OWNER PT. HOATYK
PT. PERTAMINA (Persero) MK PROJECT MANAGER SITE MANAGER QS

Name : Name : Name : Name : Name :

Date : Date : Date : Date : Date :