KIMBRATAS, PT.

Head Office & Factory : Jl. Raya Parung Panjang KM. 2, Nangsi Kav. 16, Legok – Tangerang 15820
Banten - INDONESIA
Tel : 062-21-597 8020, 597 8199 Fax : 062-21-597 8011
Homepage : www.lifechem.co.id E-mail: kimbrata@lifechem.co.id

WORK ORDER
( SURAT TUGAS )
Date / Tgl : 22 Agustus 2019 No STKL : 0193/O-03010/22/08/2019

To : Pondok Kemangi BSD As per your order No / NO. SPK/PO/Quotation

The following persons are deputed / delegated as / Document Included / Lampiran :

Kami tugaskan personil dibawah ini:  Absent Report  Set-up Treatment
 Field Activity Report  Demo Result / Hasil
1. Bapak Nanang Demo
2. Bapak Millen  Onsite Analysis  Asset Transfer
3. Bapak Dani  Survey Form
4. Bapak Rafli  Certificate of Completion / BAP
 Receipt of Equipment / Daftar Alat Diterima

To report to / Untuk melapor kepada : On Date / Pada tgl : 22 s.d 24 Agustus 2019

1. Bapak Agus Time / Waktu : 21.00 s/d selesai

LifeChem Carefully Cared

Page 1
of 5

KIMBRATAS, PT.
Head Office & Factory : Jl. Raya Parung Panjang KM. 2, Nangsi Kav. 16, Legok – Tangerang 15820
Banten - INDONESIA
Tel : 062-21-597 8020, 597 8199 Fax : 062-21-597 8011

Homepage : www.lifechem.co.id E-mail: kimbrata@lifechem.co.id

FIELD ACTIVITY REPORT
Day/Date : 2-Nov-21 STKL No : 084 /O - 04366/05/30 - 10/2021
NO ACTIVITY EVIDENCE (DOCUMENTATION)
1 KIMBRATAS, PT.
Head Office & Factory : Jl. Raya Parung Panjang KM. 2, Nangsi Kav. 16, Legok – Tangerang
15820
Banten - INDONESIA
Tel : 062-21-597 8020, 597 8199 Fax : 062-21-597 8011
Homepage : www.lifechem.co.id E-mail: kimbrata@lifechem.co.id
FIELD ACTIVITY REPORT
Day/Date : 2-Nov-21 STKL No : 084 /O - 04366/05/30 - 10/2021
NO ACTIVITY EVIDENCE (DOCUMENTATION)
1
2 Survey kondisi reservoir water (ambil foto)

3 Pengambilan sample air

 KIMBRATAS, PT.
Head Office & Factory : Jl. Raya Parung Panjang KM. 2, Nangsi Kav. 16, Legok – Tangerang 15820
Banten - INDONESIA
Tel : 062-21-597 8020, 597 8199 Fax : 062-21-597 8011
Homepage : www.lifechem.co.id E-mail: kimbrata@lifechem.co.id
Work Place / Tempat Kerja : Ruang Sistem

Addres / Alamat : BSD sektor 6 No. 7, Jl. Raya

Serpong, Lengkong Karya, Kec. Serpong Utara,
To do work as follow / Untuk mengerjakan : Kota Tangerang Selatan, Banten 15310

1. Pekerjaan Cleaning Ducting

To be completed by / Diselesaikan dalam waktu………….Days / hari…………Hours / Jam.

Remarks ( if any ) / Catatan (bila ada)

Work order delegated by / Ditugaskan oleh: Customer : Pondok Kemangi BSD

KIMBRATAS, PT. Accepts the person (s)/team to execute / Customer
menerima personil di atas untuk melaksanakan
tugasnya

(.....................................) ( ……………………... ) ( ………………………………… )

KFM Manager HRD Manager Pejabat berwenang
WORK RESULT/HASIL KERJA

LifeChem Carefully Cared

Page 2
of 5

KIMBRATAS, PT.
Head Office & Factory : Jl. Raya Parung Panjang KM. 2, Nangsi Kav. 16, Legok – Tangerang 15820
Banten - INDONESIA
Tel : 062-21-597 8020, 597 8199 Fax : 062-21-597 8011

Homepage : www.lifechem.co.id E-mail: kimbrata@lifechem.co.id

FIELD ACTIVITY REPORT
Day/Date : 2-Nov-21 STKL No : 084 /O - 04366/05/30 - 10/2021
NO ACTIVITY EVIDENCE (DOCUMENTATION)
1 KIMBRATAS, PT.
Head Office & Factory : Jl. Raya Parung Panjang KM. 2, Nangsi Kav. 16, Legok – Tangerang
15820
Banten - INDONESIA
Tel : 062-21-597 8020, 597 8199 Fax : 062-21-597 8011
Homepage : www.lifechem.co.id E-mail: kimbrata@lifechem.co.id
FIELD ACTIVITY REPORT
Day/Date : 2-Nov-21 STKL No : 084 /O - 04366/05/30 - 10/2021
NO ACTIVITY EVIDENCE (DOCUMENTATION)
1
2 Survey kondisi reservoir water (ambil foto)

3 Pengambilan sample air


The following work has been completed / Pekerjaan
yang telah selesai :
Work duration / Durasi kerja :
Technician
KIMBRATAS, PT.
Head Office & Factory : Jl. Raya Parung Panjang KM. 2, Nangsi Kav. 16, Legok – Tangerang 15820
Banten - INDONESIA
Tel : 062-21-597 8020, 597 8199 Fax : 062-21-597 8011
Homepage : www.lifechem.co.id E-mail: kimbrata@lifechem.co.id
With the result / Dengan hasil
 Accepted / Diterima
 Not Accepted / Tidak Diterima
From / Dari : …………… up to / sampai : ……………….
Customer

( ………………………. ) ( ………………………)

COMPLETION REPORT
( BERITA ACARA )
Ref No STKL : 0193/O-03010/22/08/2019 Date / Tgl :
Your Order No / No PO/SPK : Date / Tgl :

LifeChem Carefully Cared

Page 3
of 5

KIMBRATAS, PT.
Head Office & Factory : Jl. Raya Parung Panjang KM. 2, Nangsi Kav. 16, Legok – Tangerang 15820
Banten - INDONESIA
Tel : 062-21-597 8020, 597 8199 Fax : 062-21-597 8011

Homepage : www.lifechem.co.id E-mail: kimbrata@lifechem.co.id

FIELD ACTIVITY REPORT
Day/Date : 2-Nov-21 STKL No : 084 /O - 04366/05/30 - 10/2021
NO ACTIVITY EVIDENCE (DOCUMENTATION)
1 KIMBRATAS, PT.
Head Office & Factory : Jl. Raya Parung Panjang KM. 2, Nangsi Kav. 16, Legok – Tangerang
15820
Banten - INDONESIA
Tel : 062-21-597 8020, 597 8199 Fax : 062-21-597 8011
Homepage : www.lifechem.co.id E-mail: kimbrata@lifechem.co.id
FIELD ACTIVITY REPORT
Day/Date : 2-Nov-21 STKL No : 084 /O - 04366/05/30 - 10/2021
NO ACTIVITY EVIDENCE (DOCUMENTATION)
1
2 Survey kondisi reservoir water (ambil foto)

3 Pengambilan sample air

 KIMBRATAS, PT.
Head Office & Factory : Jl. Raya Parung Panjang KM. 2, Nangsi Kav. 16, Legok – Tangerang 15820
Banten - INDONESIA
Tel : 062-21-597 8020, 597 8199 Fax : 062-21-597 8011
Homepage : www.lifechem.co.id E-mail: kimbrata@lifechem.co.id
This is to certify that the following persons / Personil Customer : Pondok Kemangi BSD
kami di bawah ini : Based on the Work Order / Berdasarkan PO/SPK :
1. Bapak Nanang Date/Tgl :
2. Bapak Millen
No :
3. Bapak Dani
4. Bapak Rafli

Has completed the following works / Telah On Date / Pada Tgl :

menyelesaikan pekerjaan : Time / Waktu : 21.00 s/d selesai

1. Pengerjaan Cleaning Ducting

Work Place / Lokasi Kerja : Ruang System
Total Man hour / Jumlah jam kerja : …………..
Total Unit :

LifeChem Carefully Cared

Page 4
of 5

KIMBRATAS, PT.
Head Office & Factory : Jl. Raya Parung Panjang KM. 2, Nangsi Kav. 16, Legok – Tangerang 15820
Banten - INDONESIA
Tel : 062-21-597 8020, 597 8199 Fax : 062-21-597 8011

Homepage : www.lifechem.co.id E-mail: kimbrata@lifechem.co.id

FIELD ACTIVITY REPORT
Day/Date : 2-Nov-21 STKL No : 084 /O - 04366/05/30 - 10/2021
NO ACTIVITY EVIDENCE (DOCUMENTATION)
1 KIMBRATAS, PT.
Head Office & Factory : Jl. Raya Parung Panjang KM. 2, Nangsi Kav. 16, Legok – Tangerang
15820
Banten - INDONESIA
Tel : 062-21-597 8020, 597 8199 Fax : 062-21-597 8011
Homepage : www.lifechem.co.id E-mail: kimbrata@lifechem.co.id
FIELD ACTIVITY REPORT
Day/Date : 2-Nov-21 STKL No : 084 /O - 04366/05/30 - 10/2021
NO ACTIVITY EVIDENCE (DOCUMENTATION)
1
2 Survey kondisi reservoir water (ambil foto)

3 Pengambilan sample air

 KIMBRATAS, PT.
Head Office & Factory : Jl. Raya Parung Panjang KM. 2, Nangsi Kav. 16, Legok – Tangerang 15820
Banten - INDONESIA
Tel : 062-21-597 8020, 597 8199 Fax : 062-21-597 8011
Homepage : www.lifechem.co.id E-mail: kimbrata@lifechem.co.id

Inspected by: 1
3
Name, Date, Signature/ Name, Date, Signature/
Nama, Tgl, Ttd Nama, Tgl, Ttd
Name, Date, Signature
Nama, Tgl, Ttd
Result / Hasil Remark ( if any ) / Catatan (bila)
 Accepted / Diterima

 Not Accepted / Tidak Diterima

KIMBRATAS, PT. Customer :

( …………………….. ) ( ……………………………… )

LifeChem Carefully Cared

Page 5
of 5

KIMBRATAS, PT.
Head Office & Factory : Jl. Raya Parung Panjang KM. 2, Nangsi Kav. 16, Legok – Tangerang 15820
Banten - INDONESIA
Tel : 062-21-597 8020, 597 8199 Fax : 062-21-597 8011

Homepage : www.lifechem.co.id E-mail: kimbrata@lifechem.co.id

FIELD ACTIVITY REPORT
Day/Date : 2-Nov-21 STKL No : 084 /O - 04366/05/30 - 10/2021
NO ACTIVITY EVIDENCE (DOCUMENTATION)
1 KIMBRATAS, PT.
Head Office & Factory : Jl. Raya Parung Panjang KM. 2, Nangsi Kav. 16, Legok – Tangerang
15820
Banten - INDONESIA
Tel : 062-21-597 8020, 597 8199 Fax : 062-21-597 8011
Homepage : www.lifechem.co.id E-mail: kimbrata@lifechem.co.id
FIELD ACTIVITY REPORT
Day/Date : 2-Nov-21 STKL No : 084 /O - 04366/05/30 - 10/2021
NO ACTIVITY EVIDENCE (DOCUMENTATION)
1
2 Survey kondisi reservoir water (ambil foto)

3 Pengambilan sample air