PEMERINTAH KABUPATEN LIMA PULUH KOTA

INSPEKTORAT
TEMUAN
PADA PKPT : 2016
OBYEK PEMERIKSAAN : Dinas Peternakan dan Kesehatan Hewan Kab.Lima Puluh Kota.
SISTEM PEMERIKSAAN : Komprehensif.
TGL. PEMERIKSAAN : 07 s/d 28 Nopember 2016
No. BAGIAN TEMUAN U R A I A N

1. Temuan : ………………………………………………………………………………………………………………
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1. Kondisi: ………………………………………………………………………………………………………………
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2. Kriteria: ………………………………………………………………………………………………………………
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3. Akibat: ………………………………………………………………………………………………………………
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4. Sebab: ………………………………………………………………………………………………………………
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5. Tanggapan :
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6. Rekomendasi : ………………………………………………………………………………………………………………
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…………………………………., ………………………… 2016

TIM PEMERIKSA :

1. IZA NUDIA, ST (Ketua)

DIKETAHUI OLEH : YANG DIPERIKSA: NIP. 19820510 200803 2 001
2. Drs. MARTIUS (Anggota)
NIP. 19610312 199001 1 002
3. RISMAN (Anggota)
__________________ _________________ NIP. 19600822 198203 1 008

4. ORIZA SATIVA, S.Pd (Anggota)

NIP. 19700324 199203 2 003

5. YOSI ANHAR, A.Md (Anggota)

NIP. 19800405 201001 1 015
 SURAT PERNYATAAN

Yang bertanda tangan di bawah ini :

Na m a :
Jabatan :
Alamat :

Dengan ini menyatakan bahwa :

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Demikianlah pernyataan ini dibuat dengan sebenarnya tanpa adanya paksaan dari siapapun dan
digunakan sebagaimana mestinya

. . . . . . . . . . . . . . , 2005

Yang menyatakan,

= __________________ =
 SURAT PERNYATAAN
Yang bertanda tangan di bawah ini :
Na m a :
NIP :
Pangkat/Gol. :
Jabatan :
Alamat :

Dengan ini menyatakan bahwa :

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Demikianlah pernyataan ini dibuat dengan sebenarnya tanpa adanya paksaan dari siapapun dan
digunakan sebagaimana mestinya

. . . . . . . . . . . . . . , 2005

Yang menyatakan,

__________________
 SURAT PERNYATAAN

Yang bertanda tangan di bawah ini :

Na m a :
NIP :
Pangkat/Gol. :
Jabatan :
Alamat :

Dengan ini menyatakan bahwa :

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Demikianlah pernyataan ini dibuat dengan sebenarnya tanpa adanya paksaan dari siapapun dan
digunakan sebagaimana mestinya

. . . . . . . . . . . . . . , 2005

Yang menyatakan,

= __________________ =
NIP.