VEHICLE ACCESS APPLICATION

Requestor: Name of the requestor (personal vehicle) or of the company (company vehicle)
PT. Mitra Solusi Optimalindo
Address: Jl. Kawasan Marunda Center No. 33, Segara Makmur, Tarumajaya, Kab Bekasi 17211

Requests permission to access the zones below, at their own risk and in observance of the conditions overleaf
which both the requestor or the driver acknowledge to have read and approved.

Zone: SPV premises outside premises

Period: Start Date 21-Dec-21 End Date 31-Jul-22
Reason: deliver material container 40 ft to CAP2 Project
Vehicle: License Plate : B 9678 FEH Make & Model: HINO / FG8JE 1B-BGJ
Company vehicle
Name and address of the company that owns or leases the vehicle (if not the
requestor) :
PT. Mitra Solusi Optimalindo
Jl. Kawasan Marunda Center No. 33, Segara Makmur, Tarumajaya, Kab Bekasi 17211
Personal Vehicle
Name and address of the company that owns or leases the vehicle (if not the
requestor) :
……………………………………………………………………………..…………………………………………………….

Driver Name: Yandi

Date of Birth: 7-Jun-97
Address: Jl. Kawasan Marunda Center No. 33, Segara Makmur, Tarumajaya, Kab Bekasi 17211
Driving License: 25269706000287 Type: BII UMUM Date 22-Jun-25
Dimension of Vehicle: Long : 5485 mm Width : 2490 mm
Height : 2750 mm Load : 5.4 t
Destination location in SPV : CAP 2 PROJECT
ATTENTION
Per form only one application can be submitted◦
Application must be submitted 10 working days in advance
For EACH application either for SPV premises access or outside premises, detail information of vehicle (including height,
width, and loads) is required.

For agreement, Read and Approved,

The requestor, for contracting work, the driver,

Name and signature of the person who order the work

Imam Riva'i Yandi

Application date : 20-Dec-21

Reserved for administration:

Request denied Request approved
Access allowed to SPV premises outside premises
Escorted by: …………………………………...………………………………………… Valid until ………../ …………../ 20……….
Approver