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    43 views73 pages

    TA2839-WP05-MSC-002-R0 Unloading Container Site Office

    Uploaded by

    Denny Prayogi

    Copyright:

    © All Rights Reserved
    Download as PDF or read online from Scribd
    Flag for inappropriate content
    of 73
    WORK PERMIT FOR CONSTRUCTION SITE us [Doe Ne TTAZBS0-WPO5-PTW-002-RO Project No. TARBSS - [Ons [Unioading Container [Coordinator [Ramian Kusumayah Aetoningoiy [NPRALISA, 'SHETPTWLISA/S ha/STEMENSIR-Z0221004 — [Supervisor isan Widiandhika SIEMENS Unifower coeney om [Spesific Location [Office Sha [Safety Officer M.A. Hafiz, [Date [03-Nov-22 Number of Workers [D person PPE to be used Siandard Gioves (Shoes, Hard Hat, High Vis Vest Safety Hamess | [RubberiCotfon/Leather race Stee ones ‘Work Permit - Work Proparation Submittal Documents Checklist Ng, Submital lems for Approval ‘Approved (VesINo}"| Date Approval Sign [ssuer (Consultant) Co-Sign (lend Remarks Vi | Work planning and works mapping (layout, sequence) r. a a 7 linc in Work Method Z|Work Method Statements Z 4 © ; IA Sta Vaccinated ‘VAlsefety, Heatth and Environment Plan (incl C-19 measure) v be q+ A creat “a[Work inspections previous works (rebar, formwork, et.al.) [Survey reporistake out of the works (planned works) GIITP Inspection Test Plan document for the works (QC) [Material Approval (WorkshopiPretabricafonF actary Inspection (FAT) T | faterial Delivery, handling, laydown and storage plan w ye GE in in Work Method “| Material Delivery Inspection (Material needs to be on ste) 4 i[Meterialsampe lab test Sd party 9s required by Eng. “2|Material Test Certificates (ftom manufacturerfsupplien) “| Shop design crewings [Wale quipment planning (nand-ools, tools, heavy equipment) v7 rx incin Work Method [Ag|Equipment testing (operator and equipment certified z ye Manpower planning (per acy step, show rate of prog) ¥ oe nein Work Method “T7|Mock-up approved (if applicable) T "Z| Coorcination plan (f appicabe) | fo|Liting Pian (f applicable) TZ cz $e "20| Supervision & Qualify Control personne! planning “the above are answered with "Yes" and documents and requirements have been fulfled complete and staned above, pleas: consultant and Client Installation ting 10 br s and gain approval sign off ofthis Work Permit before any commencer Tapabla hal di ales djaweb dengan "Ya" dan dokumen seta porsyaratan tela dipenunisocara longkap den dtandatangeni,siakan undang Konsutan dan Kien unt rapat Pra-instalasi untuk mempresentastkan pekerjzen dan mendapatken persetyjuan dar in Kerja ini sobelum dimulainya pakerjaan.) ‘tot Applicable (N/A) note under ‘Remarks! (dike tidak, beri catatan a! kolom 'Remarks}) [Note Permit to Work Applicant ‘Work Permit Issuer The contractor Is required to attach documents related to the work permit Contractor CWSM | Contractor Safety Manager RHDHV PMICM UOT De saan ve mayaty cocmana np Kea i" em é i) , 4 Ld ” ) (Raman Kusumayadt) | ( Masyhurl Akmalul Hafiz) Chis nova Deena ranean ste 2a Name: Avis SetyagiiP [otiont Date: ‘oarra072 [Project Projecto. TAZ@30 [fo ERADHV site representative From PT. Slomons Indonesia [Subject 7 Method Statement Unloading Container Jwe submit the following for your approval: Method Statement o [Description lattachment and or Reference: zz ‘Signature: [To the Contractor, Your requests: Approves fo-Ateroved on condition as noted Notes: Returned for correction 1 Disapproved as noted Only for empty container date: 4 [ll [20 |FRovat Haskoningoenv nieverOwner Z ‘f > names yo [reas “wus th 2 cmon © PM RHO) Lo ee, pom TDA a apenas Tabs ROT RATT }eemeemone, rc a MARVEL 2,0 PROJECT SIEMENS HaskoningDHV undo TITLE OF DOCUMENT: METHOD STATEMENT UNLOADING SITE OFFICE CONTAINER (3 November 2022 ) DOCUMENT NO +: TA2839-WPO5-MSC-002-RO WORK PACKAGE : MARVEL 2 REV. | ISSUED DATE | STATUS | PREPARED BY | REVIEWED BY | APROVED BY ‘APROVED BY CONTRACTOR | HSE/SpvPMC. | CM/APM/PMPMC |p UO! Ramlan 00 | osWow2022 | ira dh ; be - Kar [Wer Page Lof4 2 ae us MARVEL 2.0 PROJECT HaskoningDHV Uniti SIEMENS Table of Contents > Aproval Page > Table Of Contents > Introduction > Work Planing And Work Mapping > Work Metode Statement > Safety Equipment Plan ist PPE > Manpower Plan > Material Delivery, Handling, Lay Down, And Storage Plan > Equipment Plant > Equipment Testing > Material Aproval > Safety, Healt, and Environtment Plant mu ig Plan > Material Delivery Inspection 34 5-6 79 10 10 10 11-12 B 14 14 14 14 14 Page 2of 14 a Sein Bt MARVEL 2.0 PROJECT SIEMENS HaskoningDHV Untue 1. INTRODUCTION @ Pengantar / Introdcution Work metode ini dibuat sebagai salah satu persyaratan administrasi yang harus diajukan sebelum melakukan pekerjaan di area kerja PT. Unilever Oleo Chemical Indonesia Kawasan Ekonomi Khusus Sei Mangke — Simalungun khususnya pada project ‘Marvel Il. Yang mana bertujuan untuk menilai pekerjaan dari isi SHE, Qualitas, Quantitas, dan Efisiensi waktu kerja sehingga dari metode kerja yang dilampirkan dapat disimpulkan pekerjaan ini layak atau tidak untuk dilaksanakan. This method statement was made as one of the administrative requirements that must be ‘submitted before executing the project in the work area of PT. Unilever Oleo Chemical indonesia ‘Special Economic Zone Sei Mangke ~ Simalungun, especially inthe Marvel l project. Which aims to assess the work in terms of SHE, Quality, Quantity, and Efficiency of working time, so that the work method used can be concluded whether this work is feasible or not to be carried out b. Tujuan / Objective ‘© Memastikan bahwa segala kemungkinan potensi bahaya dan resiko yang ada dalam pekerjaan ini telah teridentifikasi dan dapat dikendalikan dengan baik. Ensure that all potential hazards and risks in this work have been identified and can be properly controlled. * Menyelesaikan pekerjaan sesuai dengan kwalitas dan waktu yang direncanakan. Completing workin accordance withthe qualty and time planned. ¢.__Implementasi SHE / SHE impementation ‘© Setiap personel yang terlibat dalam kegiatan ini telah melalui system penyaringan individu dari mulai kesehatan (MCU), tindak kriminal (SKCK), dan telah melakukan Vaksinasi Cov-19. Every personnel involved in this activity has gone through an individual screening system starting from health (MCU), crime (SKCK), and has carried out the Cov-19 vaccination. ‘* Untuk mencegah kondisi dan prilaku tidak aman di tempat kerja, seluruh personel telah melakukan safety induction yang dibimbing oleh SHE PMC. To prevent unsafe conditions and behavior in the workplace, all personnel have conducted safety induction under the guidance of SHE PMC. seat Sea ne] MARVEL 2.0 PROJECT SIEMENS HaskoningDHV ucitwer * Untuk memasuki area, seluruh personel yang terlibat telah melengkapi administrasi sehingga diberikan ID card sebagai akses keluar masuk site. Toenter the area, all personnel involved have completed the administration so that an ID card is given as access to and from the site. ‘+ Untuk kelengkapan personel, PT. Siemens Indonesia menyediakan PPE sesuai standart project marvel il PT.UO! For personnel completeness, PT. Siemens Indonesia provides PPE aocording to the PT.UO! marvel I project ¢ _Setiap unit pengangkut yang akan memasuki area project marvel Ii harus dilakukan pemeriksaan sesuai standart project marvel ! PT.UOI Each transport unit that will enter the Marvel Il project area must be inspected according to the PT.UOI Marvell project standard ‘© Setiap alat berat yang digunakan untuk kegiatan loading-unloading material harus melengkapi dokumen yang valid dan dilakukan inspeksi seusai standart project marvel It Every heavy equipment used for material loading-unloading activities must complete valid documents and be inspected after the marvel Il project standard ma | Sion a waaamer | SIEMENS a | Qian | Wroyat HaskoningDHV MARVEL 2.0 PROJECT \ $2. Prova Be MARVEL 2.0 PROJECT SIEMENS HaskoningDHV unilsser b. Assesment Area Kerja /\Work Area Assessment ‘Ada beberapa hal yang harus diperhatikan dalam proses Unloading Site Office container di area Workshop Kontraktor Project Marvel Il diantaranya adalah : ‘There are several things that must be considered in the Site Office construction process in the Marvel I! Project Contractor ‘Workshop area, including © Kontisitanah di area kerja tidak begtu padat sehingga berpotens! menyebabkan tuk trbenam Land condition is flabby and potential couses the track fell © Hiab crane yang digunakan bekapasitas adalah 16 ton dan harus mencari jarak terdekat untuk menurunkan material dan bekerja dengan radius dan SWL lebih aman ‘The capacity of hiab crane is 16 Tons, it must be used nearly radius to unloading container working use safely radius and safely SWL. Page 7 of 14 een Et] MARVEL 2.0 PROJECT SIEMENS HaskoningDHV uniter + Pasang sackle pada porosnya. Put the shackes inthe center of weight ‘+ Menggantung material setinggi 10 cm dari permukaan lant tuk untuk menimbang dan mengecek kekuatan iting giar dan crane. Load test aroung 10 om high from platform of truck to check iting gear and crane capacity Setelah stabil angkat material dari truk pengangkut ke lay down area yang telah disiapkkan. ‘Atther stable, move material to the lay down area Buka webing pengikat material. (Open the material fastening weld © Bersihkan area. Clean the area + Lampiran (Skema Pengangkatan) : Attachment (Liting Schema) oe ‘aclus Max 85 meter Tag Lie “Tagine? Pe] MARVEL 2.0 PROJECT SIEMENS Royal HaskoningDHV unter + Lampiran (Posisi dan Jarak Pengangkatan) : Attachment (Position and Radius of Liting) L 4, CATATAN SHE, ENGINER, & AREA OWNER / NOTES ‘Adapun intruksi tambahan yang dapat membantu untuk menyempurnakan working metode ini saat pelasksanaan kegiatan dapat dituangkan ke dalam bentuk catatan di bawah ini: ‘The additional instructions that can help to complete this method statement during the implementation of activites can be written inthe form of notes below : “ak | Royal as MARVEL 2,0 PROJECT HaskoningDHV yas SIEMENS 5, LIST PERALATAN SAFETY / SAFETY EQUIPMENT + Garis Pengaman /Salty ine ‘+ Papan Peringatan / Safety Sign © Kotak P3K /Fist aid Kit © Radio / Handy Talky 6. LIST APD / PERSONAL PROTECTION EQUIPMENT ‘* Rompi Keselamatan / Safely Vest ‘© Sepatu Safety / Safely shoes # Kacamata Safety / Safely Google © Masker / Wiask + Safety Helmet /Safely Helmet © Sarung Tangan/ Hand Gioves 7, UST PEKERIA, PLANING + SHE +1 Orane/Person © Operator Crane 1 Orang/Person + Rigger £2 Orang/Person © Skill : 2 Orang/Person + Helper 2 Orang/Person © Driver 1 Orang/Person mene f 4 el a MARVEL 2,0 PROJECT SIEMENS HaskoningDHV untuew 8, MATERIAL DELIVERY,HANDLING, LAY DOWN, AND STORAGE © Container office Site office container ‘* Material dikirimkan menggunakan truck crane / hiab cran Materials are shipped using ruck crane / hiab eran © Titurunkan menggunakan Hiab Unloading use a Hiab Crane + Ditempatkan di dalam work shop PT. Siemens, Placed inside workshop of PT. Siemens ‘© Tutup material menggunakan terpal untuk menghindari Kerusakan pallet akibat cuaca hujan dan panas. Protecting the materials using terpaulin to protect material from rain and sunny © Lampiran gambar area penempatan Kabel. ‘Attachment of the Cable Placement area image. a. Lay Down Area Design 20 Meter e watad MARVEL 2.0 PROJECT SIEMENS Royal HaskoningDHV uniter 9. Equipment Planning + Hiab Crane 16 Ton ‘© Webing sling WLLS Ton/6 Meters , 2 Pes. © Tagline 6 meter, 2 pes © Pipe 2-3 Inch, 5-6 mm width, 2 meters Length for center as \y Page 13 of Prova HaskoningDHV Uaituwe MARVEL 2.0 PROJECT SIEMENS 10. Equipment testing © Find in attachment 11. Material Aproval ‘* Find in attachment 12. Safety, Healt, and Environtment Plant © Find in attachment 13. Lifting Plan © Find in attachment 14, Material Delivery Inspection * Find in attachment mer TPT. Unilever Oloochomical Indonesia Date: Os12022 [Project Marvel? Projecto. = TA2839 [fo {HOHV's site representative From PT. Slamons Indonesia ing Plan Unloading Cont Je submit the following for your approval: ‘O Lifting Plan a [Descrption: Jattachment and or Reference: Signature: Name: Aris SetyadiP |To the Contractor, Date 18 (uw > our requestis: ExApproved 1D Returned for correction IZ Approved on condition as noted 1 Disapproved as noted Notes: Only gor Empty Gnfainer JRoyal HaskoningDHV [UniteveriOwner Bre fame Yo tf oe ame: i based bere a eae Tr RRDRV Boerne Tobe ured ra) leone 1 cm ror 1 chert ‘ode ed ater RHOHVS 12 PM eHOHN se eoresenitie’s deesion pworae Rev 08 poraa RA Kat No 26 (Ox Fig Road) Cando aes en rmtey REQUEST FOR APPROVAL ‘Some, TADRsEvPaSAEC 4020 Trent PT. Unilever Oleochemical indonesia Date ‘orti2022 rojeck Marvel Projecto, TARB39 [Te {_RHDHV's site representative From PT, Siemens Indonesia Subject /e submit the following for your approval Equipment Testing a Jbescrston: Jattachment and or Reference: L wee Signature: Name: Avie SetyadliP [ro the Contractor, four request is: trReproved 1D Approved on condition as noted TEquipment Testing Unloading Container Returned for correction {D Disapproved as noted Date:_1Of fi | ce: ‘Poyal HaskoningDHV Juniteveriowner | % oe = wee tas 44 TT UA Yang Meayetaion ae ee ee le slenaratent be pan ry OSE OTST ont Seen ee Tats es Certificate ig aman er rena rio Sn mi Fe ee en memati dar Eropa EW 1424 Sc FANN A 14135 or Ln Yoo Menytatne ps fpr wneenmerneeanprenerseenpiers talented ee ete Sertifikat — sis eT Tat ‘=a 2801 Danson RA Taka OK 24110 Certificate of Conformance Ceriieate Number: 1-2017090300069 Location of Issue: Crosby 2801 Dawson Rd Tuba, OK 74110 USA Phone: 918-834-4611 Fax: 918-852-0940 Stock No: 1019597 Description of Gear: _G2130_12t Bolt Type Anchor Shackle 1-1-4" Mantoughit ‘Working Load Limit, 121] [Max Allowed Proof Load: 244 {indicates metre tons Comments: Minimum ultimate strength is 6 times the WLL Note: Meets the performance requirements of Federal Specification RR-C-271F Type IVA, rade A, Class 3, except for those provisions required ofthe contractor. Meets or exceeds all requirements of ASML B30.26, Crosby Forged shackles can be used in genera verve with yood ri down to temperatures of 40 °F (40°C). Has not been contaminated hy Mercury oF Asbestos in the manufacturing process, Number of Pieces: 4 Bow: SNE ICS are based on visual observation Certificate based on item being the Cresby product deseribed above. ing practice \We herehy ceri thatthe above described material was manufactured and processed ina manner compatite to the load ratings when used wader normal and proper applics sertoned products aren conformity athe Crosby tierature available at rime of manufactring.incudine the Following trademarked Features: This certificate was requested by our Crosby Authorized Distributor: PTSUPRA TALINDO CO LTD For Pract Daiered To: PT; PRAKARSALANGGENG MAJUBERSAMA, JAKARTA Indonesia Customer (User) Order Number: A1740221 a Senvcrider 04,2017 poke ae Sm Signature: eal Dic oF une 1 Wapranson Crabs Ovals Assn Mama ae “ye met 2801 Dawson Rd Tulsa, OK 74170 Seccsesaeen Certificate of Conformance Cenieate Number: €C1-201705050069 Location of lssus Crosby 201 Dawson Rd Tula OK T4110 USA Phone; 918-834-4611 Fax: 918-832-0040 Stock No: 1019597 Description of Gear;_G2130 121 Bolt Type Anchor Shackle 1-1/4" Maxtoughi Working Luad Limit. 12t} [Mas. Allowed Proof Load: 231] ‘indicates metric tons Comments: Minimum ultimate strength is 6 times the WI. Note: Meets the performance requirements of Federal Specification RR-C-271¥ Type IVA. Grade A, Clas 3. except for those provisions required of the contractor. Meets or exceeds all requirements of ASME 830.26 Crosby forged shackles can be used in general service with youd rigging practice down to temperatures of 40 °F (-40°C) Has not been contaminated by Mercury or Asbestos inthe manufacturing process Number of Pieces: 4 Bow: SNE ICs are based on visual obser Certificate based on item being the Crosby produet described above. ‘We hereby certify tha the above described materia] was manufactured and processed ina manner compatible to rect the load ratings when used wnder normal and proper applications Mentioned prducts aren conformity tothe Crosby literture available atime of manufacturing, lnclating the following vademarked estates: EEE oad Ged ited “|” MAMOUGH === CE “This certificate wus requested by our Crosby Authorized Distributor: PT SUPRA TALINDO CO LTD For Product Deliver To PT. PRAKARSALANGGENG MAJUBERSAMA JAKARTA Indonesia Customer (ser Onder Number: AN7S0221 Tae age 3 1a Sepiember 04,2017, ae Dac oF stance Daid Magnan. Cont Qiliy Wonnee Ma eye Soremee 2801 Dawson Rd Tulsa OK 74110 Certificate of Conformance Centitieate Number: CC1-2017090400069 Location oF tssve: Crosby 2RO1 Dawson Rd Tulsa. OK 74110 USA Phone: 918-834-4611 Fax: 918-832-0940 Stock No: 1019597 Description of Gear._G2130_12t Bolt Type Anchor Shackle 1-1/4" Maxtouehit [Working Load Limit 121] [Max Allowed Proof Load: 2: Comments: Minimum ultimate strength is 6 times the WL. Nore: Meets the performance requirements of Federal Specification RR-C-271F Type IVA. ‘Grade A. Class 3. except for those provisions required ofthe contractor. Meets or exceeds all requirements of ASME B30.26. Crosby forged shackles can be sed in genera serie with youd rigging practice down to temperatures of 10 °F (40°C), Has not been contaminated by Mercury oF Ashestos in the manufacturing process, NumberofPieces: 4 Bow: SNE PICs are based on visual observation Certificate based on itom being the Crexby product deserihed shove, ‘indicates metric tons ‘We hereby cert thatthe above described material was manufactured and proceed in a manner compile to meetin the load ratings when used under normal and proper application. eetioned produc ar in conformity tothe Crosby Iierature available st ime of manuficrring. inching the ‘Swing vase aes ——— GEER Coed Feed Feique Rad“) MAXTOUGH This certificate was requested by our Crosby Authorized Distributor: PT SUPRA TALINDO CO LTD or Product Delivered To PT. PRAKARSALANGGENG MAJUBERSAMA JAKARTA Indonesia (Customer (User) Order Number: ANTAO221 be September 04,2017 MAXTOUGH HCE EE “This certificate was requested by our Crasby Authorized Distributor: PT SUPRA TALINDO CO LTD or Prodoct Delivered To: PT. PRAKARSALANGGENG MAJUBERSAMA INKARTA Indeosia Customer (Use Order Number: AI740283 an ee ce Date of sane: ntl Magne Coby Quy Rosa MOET bapa Semen oven ‘sommes 2401 Dawson Rd Tulsa, OK 74110) sew thera ou com Certificate of Conformance CCenificate Number: CCI-2017101100831 Location of Issue: Crosby 2801 Dawson Rd Tuk, OK 74110 USA Phone: 918-834-4611 Fax: 918-852-0940 Stock No: 1019533 Description of Gear:_G2130 6-1/2 Bolt Type Anchor Shackle 7/8" Maxtoush’® | indicates metric tons ‘Comments: Minimum ultimate strength is 6 times the WLL ‘Note: Meets the performance requirenents of Federal Specification RR-C-271F Type IVA. Grade A. Class 3, except for those provisions required of te contractor. Meets or exceeds all requirements of ASME. 130.26. Crosby forged shackles can be weed in general service with good rigging practice down to temperatures of 40°F (40°C), Has not been contaminated by Mereury or Asbestos in the manufacturing process. Number of Pieces: 1B Bow: 5IK PICs are based on visual observation CCenticate sod om itean being the Croshy product described above We hereby ceri thatthe above described material was manufactured and procesedin& manner compatible to _ceting the load ratings when ued under normal and proper applications. Mentioned products are in cantor tothe Crosby Hterature avaiable at time of manufacturing including the {allowing trademarked features: Fe Lond ead Fitiqne Rand “7” MAMOUGH Ee CE. “This certifeate was requested by our Crosby Authorized Distributor: PT SUPRA TALINDO CO LTD. For Product Delivered To: PI. PRAKARSALANGGENG MAJUBFRSAMA JAKARTA, Indonesia Customer (User) Onder Number: A1740283 be 1.207 sue _ DHE Mapes — ae ee Tc of sen David Magnan. Crabs Gus Asace Mansa bela 201 Dawson Rd Tulsa, OK 74110 sewer onc Certificate of Conformance CCeniticate Number: CC1-2017101100831 Location of Issue Crosby 2801 Dawson Rd ‘Tulsa, OK 74110 USA Phone: 918-834-4611 Fax: 918-832-0940 Stock No; 1019533 Deseription of Gear:_G2130 6-12 Bo Type Anshor Shackle 7/4” Mastough® SEs Comments: Minin uma strength 6 ines he WL. Move. Morse perfomance rautamems of Federal Specficon RR-C-271F Type VA, (Goad A, Clas 3. ecep fur tose porns rune cori. Mow or encod al requirments of ASMI B3026, (Crosby ered sbckles can be sed in goer sevice wit good rigging practice dawn emperturs of 10°F (40°C) Hasot Bon contaminated by Mercury r Asbestos nthe manufacturing procs Number of Pisses: 8 Bow: 3K Fiore based visual servation Cerin tel on te being the Cros product esrted above ‘We hereby certify thatthe above decribed material was manulicured and processed ina manner compatible 19 meeting the load ratings when used under normal and proper applications. Mentioned product ren conformity tothe Crosy iterxure available a time of manufacturing. including the MAXIOUGH B= CE. “This certificate was requested by our Crosby Authorized Distributor; PT SUPRA TALINDO CO LTD For Product Delivered To: PI. PRAKARSALANGGENG MAJUBERSAMA, JAKARTA, Indonesia Customer (User) Onder Number: A1TAO283 a be 2017 Sige, POE Mespaxso——__ a SS + 449 ie 01 Dassson Rd Tulsa OK 74110 sewer oun com Certificate of Conformance CCenifioate Number: CC1-2017101100826 Location of Issue: Crosby 22801 Dawson Rd Tulsa. OK 74110 USA, Phone: 918-634-4611 Fax: 918-832-0940 1019490 62130 3.1/4 Bol Type Anchor Shackle 5/8" Maxtoughf iat ‘indicates merc tons Minimum ukimate strength is 6 times the WL Meets the performance requirements of Federal Specification RR-C-271F Type IVA. Grade A. Cass 3. excep for those provisions required ofthe contractor. Meats or exceed ll equirements of ASME B3026, Crosby forged shackles can be use in general service with good rigging practice down to temperate of 40°F (10°C) Has not been contaminated by Mercury or Asbestos inthe manufacturing process. Number of Pieces: 24 Bow: TRE ICS are based on visual observation ‘Centfieae bes on item being the Crosby product described above, Wis hesby esti tht he above decried material wae manafictred aed processed na anner compatible to meeting the load rings when used under normal and proper applic. Mentioned ruc aren conformity to the Crosby iterate available atime of manufacturing inchading the following vademarked eaunes EERE (sod Toad Filles Rad “7” MAMTOUGH' Ea CE ‘This certificate was requested by our Crusby Authorized Distribator: PT SUPRA TALINDO CO LTD For Product Delivered To: PF. PRAKARSALANGGENG MAJUBERSAMA JAKARTA Indonesia Costomer (User) Onder Number: AITA0283 Pk a Cer ae ced Sanne bof =m Gresby eae 2801 Dawson Rd Tuba. OK 74110 sew theron com Certificate of Conformance CCeniticate Number: CC1-2017101100826 Location of Issue: Crosby 201 Dawson Rd Tulsa, OK 74110 USA Phone: 918-834-4611 Fax: 918-832.0040 Stock No: 1019490 Description of Gear:_G2130 3-1/4 Bolt Type Anchor Shackle 5/8" Maxtoughi [Working Load Limit 3-1/4} (Max. Allowed Proof Laed: 6-1/2 ‘indicates metic tons ‘Comments: Minimm ultimate strength is 6 times the WILL "Note: Meets the performance requirements of Federal Speifiation RR-C-271F Type IVA. Gade A. Class 3, excep fr those provisions required of we contractor. “Mees or exceeds all requirements of ASME B30.26. ‘Crosby forged shackles can be used in general service with good rigging practice down to temperatures of 40 °F (-40 °C). Has not been contaminated by Mercury or Asbestos in the manufacturing process Number of Pieces: 24 Bow: TRB ICS are based on visual observation Ceniiene based on tem being the Crosby product described above. We hereby cet tht the above described material was manufactred and processed na nanner compe meeting the lad rags when used ander normal and proper applications te Mentioned rts ain conformity to the Crosby Iteratur available atime of manufacacing. ochading folowing cademarked fetes: TEES Land Feat File ard “<> MAMTOUGH He CE "This certificate was requested by our Crusby Authorized Distributor: PT SUPRA TALINDO CO LTD For Pradact Delivered To: PY, PRAKARSALANGGENG MAJUBERSAMA, JAKARTA Indonesia ‘Customer (User) Order Number: AN740283 Si “soon se 2801 Dawson Rd Tuka, OK 74110 ‘wether con Certificate of Conformance Ceniticate Number: CC1-2017101100826 Location of Issue: Crosby 201 Dawson Ré Tulsa, OK 74110 USA, Phone: 918-834-4611 Fax 918.852.0040 Stock No: 1019490 Description of Gear:_G2130 3-1/4 Bol Type Anchor Shackle $8" Maioug® [Max Allowed Proof toad 121] indices ei ta Comment: Minin shimat strengths 6 tines te WLL Nae: Meas he efomance equines of Fedcal Speifeaton RR-C-271F Type VA, Gand A las 3.x forthe roses equ oth cone. Meet or xen all rmutemens of ASME B3O26 ab Gael sche Ga be eed wees wo goed agg mie. down temperate of 40"F (40°C) pt ere arene by caro Ae oc Number of iees: 24 Bow: TRB ecg el ee Coricat bud on om bing the Crosby produc decibel above ‘We hesby set thatthe above described material as manufrured and procesed in a han compat to meeting the lad ratings when used der normal and proper application. Mentioned produces are i conformity to the Crosby Htralure available ane of manufacturing, including the Folin uacemared etures TEBE ood Tad Fitigee ed “7” MAMTOUGH Ee CE ‘This certificate was requested by our Crosby Authorized Distributor: PT SUPRA TALINDO CO LTD or Pract Delivered To: PT, PRAKARSALANGGENG MAJUBERSAMA IRKARIA Indonesia {Customer (User) Onder Number: AL740283 cabo 11,2017 Date: 4 fr No, Dokumen PT UNII OLE® Al u -F-SHE-x00 LEVER OLEOCHEMICAL INDONESIA [10 TOT” |: UOL-F-SHE-00 DAFTAR PERIKSA WEBBING SLING No, Terbitan WEBBING SLING INSPECTION CHECKLIST Issue No, Tanggal Inspeksi Inspection Date Kontraktor Contractor Kapasitas Capacity Parameter Inspeksi Inspection Paramet Gambar Panduan Guide Photo [Tidak ada jahitan yang putus INo Broken Stitches Tidak ada lubang ataupun robek pada webbing INo note or cut 3 {Tidak aga ikatan ue B 4 oot a 4 Ino Heat ‘Mechanical or Chemical Damage are HTicak ada kerusakan pags eye a lwo damaged eye |Labe! pada webbing masin terinat jelas _ ILegible faber tag on webbing 7 [Serikat Pabric Seriikat Kesesuaan lai Certicate / Certficate of Conformance "dontifikasibagian mana pun untuk menemukan cacat yang dapat membahayakan orang dan des\ripal caval Uika dak ada menyatakan TIOAR ‘ADA, sorta porsyaratan untuk memperbaiki cacat: ‘entficaton of any partto found a defect which i or could become 2 danger fo persons and a description of the defect (# none state NONE) also the ‘raqurement to rectly the defect Faatan Note ~ Diinspeksi Olen —Diverifikast O1er Jospected By Verified bs = | Bp Diage ae —— PT UNILEVER OLEOCHEMICAL INDONESIA [N° Dokumen boy SHE ex Document No, DAFTAR PERIKSA WEBBING SLING INo. Terbitan WEBBING SLING INSPECTION CHECKLIST Issue No. Tanggal Inspeksi ol - UA 22 Inspection Date = Kontraktor pr. Pres Contractor Kapasitas : on Capacty My - 0/9 - wy Fast va Parameter inspeksi Result Gambar Panduan inspecton Parameter 7x Gunde Photo 4 [Tidak ade jahitan yang putus | fe 2 No Broken Stiches Tidak ace lubang ataupun robek pada webbing — | te 2 No hole or cut ( a 3 Ino knot 1 Roe At Pee etn hor ee Ie Heb ee a ee 55, | Tidak ada kerusakan pada eye K |No damaged eye ¢g_ |t2del pada webbing masih teria jetas u ILegile fabe! tag on webbing 7 [Seria Patrik Seniixat Kesesvaan Mit Certficate / Certificate of Conformance ntikasi bagian mana pun untuk manemukan cacat yang Gapat mombahayakan orang dan deskripsi cacat Ua Udak ada menyatakan TIDAK ‘ADA), serta persyaratan untuk momperbaiki cacat: ‘Identicaton of any pat to found a defect which sor could become a danger o persons and a deseripton of the defect (i none state NONE) also the pen era mee TH Diinsperst Oleh Diverifikast Oleh Diselujur deh Jnspected By Verified by Approved by oS Eyal Hi Aa No. Dokumen Document No PT UNILEVER OLEOCHEMICAL INDONESIA. UOL-F-SHE-»x. DAFTAR PERIKSA WEBBING SLING WEBBING SLING INSPECTION CHECKLIST No. Terbitan Issue No Tanggal inspeksi Inspection Date Kontraktor Contractor Kapasitas Capacity Parameter Inspeksi Inspection Parameter Gambar Panduan Guide Photo 4 [Tidak ada jahitan yang putus INo Broken Stitches 12. |Tidak ada lubang ataupun robek pada webbing |No hole or cut 3 [Tidak ada ikatan Ino knot 14, {Tl0ak Rusak Akibat Panas, Mekanis bahan kimia INo Heat, Mechanical or Chemical Damage 55, |Tidak ada kerusakan peda eye No damaged eye lLabe! pada webbing masih terlnatjetas lLegible label tag on webbing 7, Seriikat Pabric7 Serial Kesesuaien Mil Certiicate / Cerificate of Conformance Identifikasi bagian mana pun untuk menemutan caval yang dapat membahayekan orang dan doshipal cacat Gi ADA), serta persyaratan untuk memporbaiki cacat: ‘denvicaton of ony pat to found a defect which is or could become a danger to persons and 2 deserion of he defect (f none state NONE), also the ‘requirement to rectly the defect tidak ada monyatakan TIDAK iatanTNaler DIRSpEKST OTE DVETIFaST OTE Disstaqu eA Inspected By Verified by Approved by a Bae Aung}? Bek cP a PT UNILEVER OLEOCHEMICAL INDONESIA No, Dokumen UOL-F-SHE-»x Document No, DAFTAR PERIKSA WEBBING SLING WEBBING SLING INSPECTION CHECKLIST Tanggal nspeksi Inspection Date POl-H-22 Kontraktor . Contractor PME: Kapasitas : Capacity : me OCP us Taal i Parameter Inspeksi sul Gambar Panduan Insgeaton Perameter > Guide Photo fide ada jaitan yang puts Wo Broken Siches A 2 [Tidak oda ubang atoupun robek pada webbing | “| uo iote or eut 3, [Tidak oa ikatan — ae No knot ” eee 1g, [leak Rusak Akbat Panes. Mekanis/bahan mia | Le ee }vo Hoat, Mechanical or Chemica Damage see [dak ada kerusakan pace eye 5 |noaamaged eve UL L2be! pace webbing masin erat jes © |Log tabet tag on webding a 7 | SARK PabA Sarre Resenuaian Mil Ceticate/ Cerca of Conformance —_ dontifkasi bagion mana pun untuk menemukan cacat yang dapat mombahayakan orang Gan deskripalcacat Gia dak ade menyalavan TIDAK ADA), serta perayaratan untuk momperbaiki cacat: tiieaten of any part to found » defect which sor could become @ danger to persons and 2 descipion of the elect (# none state NONE), also the nt requirement to rectly the detect [Eaatan Wate DiinspeKst Oleh Diveniikasr Teh Dsetjur Ore Jnspected By Verified by Approved by wae PT UNILEVER OLEOCHEMICAL INDONESIA |NO-Dokumen | G1 6 sie se Document No, DAFTAR PERIKSA WEBBING SLING WEBBING SLING INSPECTION CHECKLIST Tanggal inspeksi eae Inspection Date O22 Kontraktor . Contractor 3 PT. Pee Kapasitas . Capacity . MB- 06 -ws a Parameter Inspeks! result Gambar Panduan Inspection Parameter Guide Photo Tidak ada jahitan yang putus No Broken Stiches f 2. [Tidak ada lubang taupun robek pada webbing No thle or cut C44 3, [Tidak ada katan Wo knot 4, |Tidak Rusak Akibat Panas, Mekanis / bahan kimia |No Heat, Mechanical or Chemical Damage ( 55, [Tidak ada kerusakan pada eye lNo damaged aye { [betel pada webbing masih tertinat elas |Legible lade! tag on webbing al Sritikat Pabrik Seriicat Kesesusien mil Certfcate / Certificate of Conformance =I "dentfikasi bagian mena pun untuk menemukan cacat yang Gapat membahayakan orang dan doskripal cecal Uika dak ada manyatakan OAK ‘ADA), sorta persyaratan untuk memperbalki cacet: ‘certitcatin of any porto found a defect which sor couk become @ denger to persons and = description of the defect (4 none state NONE). also the requirement to recty the defect. Satan Note: DInsparsT OTe DIVEST Oar DSSTOyT OF Inspected By Verified by Approved by ver PT UNILEVER OLEOCHEMICAL INDONESIA —|N°: Dokumen |. oye. SHE ex Document No DAFTAR PERIKSA WEBBING SLING WEBBING SLING INSPECTION CHECKLIST Tanggal Inspoksi _ eee Inspection Date 7 ila Kontraktor Contractor PPT. Pap Kapasitas I Capacity : ; MB OE -ws Tas Ne Parameter Inspeksi p= Gambar Panduan . Inspection Porameter Gude Proto 4 [Tidak ada jahitan yang puts No Biraken Stitches 2 |Tidok ada tubang ataupun robek pada webbing |No hole or cut [Tidak ada katan INo knot Tidak Rusak Akibat Panas, Mekanis / bahan kimia INo Heat, Mechanical or Chemical Damage «5. |Tidak ada kerusakan pada eve INo damaged eye lLabe! pada webbing masin terinat elas |Legrle fabo! tag on webbing CLO ESS fs 7 [Semiikat Pabric 7 Senitkat Kesesuaion [Mi Certificate / Certificate of Conformance "dentifikasi bagian mana pun untuk menemukan cacat yang dapat membahayakan orang dan Geskripel cacat (ike Udak ada menyalakan TIDAK ADA), serta persyaratan untuk memperbalki cacat: dentiication of any pert to found a defect which is or could become a danger to persons and description ofthe defect (f nove state NONE), also the requirement to recy the defect [Sstatan 7 Noter TIIASpERST OR “DIVeTTRGST ORT DST OER Inspected By | Vented by Approved by yo VA —asar Hitrep Ark cape PT UNILEVER OLEOCHEMICAL INDONESIA DAFTAR PERIKSA WEBBING SLING WEBBING SLING INSPECTION CHECKLIST INo. Dokumen, Document No, UOI-F-SHE-x9%« Tanggal Inspeksi Inspection Date Kontraktor Contractor Kapasitas Capacity na Parameter inspeksi " Inspection Parameter [Tidak ada jahitan yang putus \Wo Broken Stitches 2. {Tidak ada lubang ataupun robek pada webbing |No hole or cut [Tidak ada katan Iwo knot [Tidak Rusak Akibat Panas, Mekanis /bahan kimia |Wo Heat, Mechanical or Chemical Damage Gambar Panduan Guide Photo \Tidak ada kerusakan pada eye 5 |o damaged eye g, {tabe! pace webbing masin ternatjelas Legible tabel tag on webbing 7_[Sentikat Pabrik 7 Serttikat Kesesuaan lain Certificate / Certficste of Conformance “dentifixasi bagian mana pun untuk menemukan cacat ya ‘dapat membahayakan orang dan doskripal cacat(ika dak ada menyatakan TOAK ‘ADA), serta persyaratan untuk memperbsiki cacat: ‘dentition of any part to found » defect which sor could become a danger to persons and @ description ofthe defect (# none state NONE), also the ‘requrement fo rectly the defect Satan T Note Diinspeksi Oleh Diveriikasi OF Diselajur oleh Inspected By Verified by. mae x Bape Hiae BO Toa ke PT UNILEVER OLEOCHEMICAL INDONESIA —|NO: Dokumen | Go1.¢. sie sx [Document No. No. Terbitan issue No DAFTAR PERIKSA WEBBING SLING. WEBBING SLING INSPECTION CHECKLIST Tanggal Inspeksi Inspection Cate Kontraktor Contractor tae Kapasitas Capacity 2 S , * w x “MB 0/3 -ws oy Parameter inspeks! 7 Inspection Parameter Gambar Panduan Guide Photo [Tidak ada jahitan yang putus Wo Broken Stiches 2, [Tidak ada tubang ataupun robek pada webbing |No hale or cut No knot 14, {Tidak Rusak Akivat Panas, Mekanis /bahan kimia |No Heat, Mechanical or Chemical Damage \Tidak ada kerusakan pada eye D a 5 |No damaged eye abe pade wetting mash teat jets © |Leaibie abel tag on webbing wv] — 7 [Seriikat Pabrk [Sertfat Kesesvaian [Mi Certificate / Certificate of Conformance uM | fridok ada katan - i Y v1 oa Xe ‘entifixasi bagian mana pun untuk menemukan eacat yang dapat membahayakan orang dan deskripal caval Gika dak ada menyatakan TIDAR ‘ADA), serta persyaratan untuk memparbalk cacat: ‘centitcaten of any pero found » defect whvch 1s or could become 2 danger to perso and descrition ofthe defect (none state NONE). also the requirement to rectly the detect: Diinspeksi Oleh Divertikasi Oleh Diseligur oer Inspected By Verified by Baphs Binge BED TO No. Dokumer PT UNILEVER OLEOCHEMICAL INDONESIA |°. TORO DAFTAR PERIKSA WEBBING SLING. No. Terbitan WEBBING SLING INSPECTION CHECKLIST Issue No. fn lo. UOI-F-SHE-x0%. Tanggal inspeksi inspection Date ae laas Kontraktor Contractor ee Kapasitas 5 Capacity 2 MB - 012 = ws Parameter inspeksi Result Inspection Parameter 4, [Tidak ada jatitan yang putus INo Broken Stitches 2. [Tidak ada lubang ataupun robek pada webbing INo hole or cut ( Gambar Panduan aul aa Guide Photo 5 [Tidak ada kerusakan pada eye «g. |{-#be! pads webbing masin teria elas ILegble fabe! tag on webbing [Tidak ada ikatan E 3 3 |Wo knot 14 {Tidak Rusak Akibot Panes, Mekanis bahan kmia INo Heat Mechanical or Chemicel Damage 7 [Sertiikat Pabrk [Serihkat Kesesuaian Mit Certificate / Cerificate of Conformance uw a lNo damaged eye “| vw —| ‘ADA), sorta perayaratan untuk memperbaiki eacat: ‘dentiixasibagian mana pun untuk menemukan cacat yang dapat membahayakan orang dan devkripalcecat (ka dak ada menyatavan TIOAK ‘Gentitcaton of any part to found » defect which sor could become a danger to persons ard 2 description ofthe defect (none tate NONE). aso the ‘requirement fect the detec: aan TR DiinS paket OTE Diverikast Oleh Disetyjor oleh Inspected By Verified by Approved by = SL 4 < | [____Feguy Boe i Tul ber wet PT UNILEVER OLEOCHEMICAL INDONESIA UOL-F-SHE-xxx DAFTAR PERIKSA WEBBING SLING. WEBBING SLING INSPECTION CHECKLIST Tanggal Inspeksi | ae Inspection Date corey a? Kontraktor Contractor eT Kapasitas Capacity Me - Off ws Taal im Parameter Inspeks! result Gambar Panduan ~ Inspection Parameter i aa Guide Photo —————E r z deka jaitan yang putes 1 |no Broken Sitches v Tidak ada bang staupun robek pad webbing 2 | hole or cut — 3 {Tidak ada ikatan > S |No knot Ve 1g |Tidok Rusak Akbat Panas, Mekens/bahan Knia No Heat, Mechanica or Chemical Damage wa 5 [Tidak ada kerusakan pada eye e 5 No damaged oye ve 5 [tebe pad webbing main ena jis ay Leaite abe! tog on webbing 7 [Serial Pabakc Serial Kesesvaian FF 7 i Conese / Ceniicate of Conformance ‘dentikasi bagian mana pun untuk menemukan eatat yang dapat membahayakan orang dan GesKripelcacat Gia dak ada menyatakan TIDAK ADA), sorta persyaratan untuk memperbaiki cacat: ‘entifcation of any pert t found @ defect which i or could become 9 danger to persons and a desertion of he defect (é none state NONE}. eso the requirement to oct the detect atalan Note: Diinspeksi Olen Diveriikasi Oe Disetujui oleh Jospected By Verified by. Re Tae oft ee ee Vie i Unilever PT UNILEVER OLEOCHEMICAL INDONESIA DAFTAR PERIKSA FULL BODY HARNESS, FULL BODY HARNESS INSPECTION CHECKLIST Tanggal Inspeksi Inspection Date Kontraktor Contractor Nomor Alat Equipment Number é Parameter ins Inspection Parameter Ol y-g2 : PT. PRAKARSALANGGENG MAJU BERSAMA O97 ~Fo4 2 ge Fast | Result x [Sabuk Harness |Hamess Webbing or Leather v7 a 2 [Seluruh Janitan [Au Stiching 3 [PRing & Gesper lo Ring & Bucie 4 [eavere lLanyara 5 [Pengait& Safety Latch [Hook & Safety Latch «5 [Peredam Kejutan [Shock arbsorber untuk memperbakicacat: niiasl agian mars pun untuk menemukan cacat yang dapel membar heyeken orang dan deskripsl cacat ka Udax ada menyelakan TIDAK ADA), sur] Diveniikasi Oleh Disetyui oleh Ope) Loa Of TIN PT UNILEVER OLEOCHEMICAL INDONESIA DAFTAR PERIKSA FULL BODY HARNESS Unilever FULL BODY HARNESS INSPECTION CHECKLIST Tangga!nspeksi id inspecton Dat pos 22 arse "PT. PRAKARSALANGGENG MAJU BERSAMA Nomor Alat . Equipment Number Ms 09D —Fo4 T Parameter Inspeks! Result Gambar Panduan Inspecton Parameter Jz Guide Photo [Sabuk Harness [Hames Webbing or Leather 2 [Seluruh Jahitan ‘Stitching | 3 [Ring & Gesper ID Ring & Buckle 4 [paver Lanyarcs [Pengait & Safoty Latch 5 look & Safety Latch [Peredam Kojutan [Shock arbsorber n mana pun untuk menemuten cacat yang dapat membeho) ik mempersik cacat: trtncaton of any pat found 3 detect which iso ould become a iy te dec yakan orang Gan Geshrpsl cacat (jks Udak ada menyatakon TIOAK ADA), danger to parsons and a description of he defect if mare stte NONE), also the requirement o ian Note Diinspeksi Oleh Diverifikasi Oleh, Disetujui oleh At ye Eee = CSTE PT UNILEVER OLEOCHEMICAL INDONESIA eo ‘ee A DAFTAR PERIKSA FULL BODY HARNESS Value 8 Unilever FULL BODY HARNESS INSPECTION CHECKLIST ety ‘Tanggal inspeksi 2 pert 22 Inspection Date 7 Kentraltor “PT. PRAKARSALANGGENG MALU BERSAA Notnor Alat Eqipment Number Ms - 099 - Fox Parameter nspoksi amber Panduen Inspecton Parameter a Gui Pete 7 [Sabak tamess : fi JHamess Webbing or Lathr t : Selruh Jnitan — a 2 JAll Stitching 2 > [Pina & Geaper 5 orang a Bette 4 [tanyerd 4 Canyon 1 > [Penoait a Safety Latch : oo & Safty tata [Peretam Rejtan é Shoat absorber femmes ‘agian man pun untuk menemokan cacat yang dapat membahayatan orang dan deskrips!cacat Uka Gaak ada mentation TIDAK ADA), sera] reyarotan untuk momperbsiki eacat fanticaton of ary part found« detec! which iso oul! become 8 danger to persons and @ description othe delect if nn sate NONE}. sls the requremer! to fester wo aetoce satan Woe Diinspeksi Oleh Diverifikasi Oleh Disetqul oleh Zar oie Tyen7 TILIA) oO fet PT UNILEVER OLEOCHEMICAL INDONESIA DAFTAR PERIKSA FULL BODY HARNESS, FULL BODY HARNESS INSPECTION CHECKLIST ‘Tanggal Inspeksi Inspection Date Kontraktor Contractor Nomor Alat Equipment Number Pa Parameter inspekst Inspection Parameter LP Una : PT. PRAKARSALANGGENG MAJU BERSAMA, MB. 100 Fo Tae Result ‘Gambar Panduan ‘Guido Photo |Sabuk Hamess [Hames Webbing or Leather 2 [Seluruh Jahitan [aN Sttening 3 |PRing & Gesper lO Ring & Buckle g [banverd lLanyart '5 [Pengait & Safety Latch [Hook & Safety Latch redam Kejutan Shock arbsorber rsyaratan untuk memperbaiki eat: iy the otec: denutkas! bagian ana pun untuk menemukan cocot yang dapat membahayakan Or nication of any porto founda detect which i or could become a danger to gersans and a desertion ofthe éeect if nae sate NONE), as the requirement fo] jan deskripslcacat (ta Udak ada menyatakan TIDAK ADA), se Diseijui oleh St Wy ina Ta teh PT UNILEVER OLEOCHEMICAL INDONESIA DAFTAR PERIKSA FULL BODY HARNESS FULL BODY HARNESS INSPECTION CHECKLIST Tanggal inspeksi wai NT Inspection Date s Ose 1/2 Kontraktor Contractor : PT. PRAKARSALANGGENG MAJU BERSAMA Nomor Alat Hl Equipment Number SUB 107 Foy at rameter nspeksi Result Gambar Panduan inspection Parameter ‘Guide Photo 7 [Sabuk Hamess |Hamess Webbing or Leather [Seturuh Janitan 2 Tau stiching 2 [P Ring & Gesper lo Ring & Buckle ILanyar Lanyard «5 [Pengait & Safety Latch look & Safety Latch }éentikas! begian mane pun untuk menemokan cacat yang dapat membahayehan orang dan deahripsl carat (ke dak ada menyalatan TIDAK ADA) sera] rayaratan untuk memparosik eset: cation of any part Tofund » detect which i or couls Become» danger to preons end a descrption o the éelct inane sate NONE}, sso ne requremart tl fy tho dele otatan Notes Diinspeksi Oleh Diverifikasi Oleh Disetujui oleh Ped a ol [Tt Veh PT UNILEVER OLEOCHEMICAL INDONESIA = DAFTAR PERIKSA FULL BODY HARNESS Unilever FULL BODY HARNESS INSPECTION CHECKLIST 63 eugus 8 Tanggal Inspeksi Inspection Date Kontraktor Contractor Nomor Alat Equipment Number = arameter Inspoksi Ingpecton Parameter 20/7 Ur2R , : PT. PRAKARSALANGGENG MAJU BERSAMA We -/o2d -Fo4 Gambar Panduan Guide Photo [Sabuk Hames Harness Webbing or Leather 2 [Seturuh Jahitan |at Sticring 3 [Ring & Gesper [0 Ring & Buckle [Lanyara Lanyard ¢5_[Pengait& Safety Laten Hook & Safety Latch [Peredam Kejutan [Shock artsorber rsyratan Untuk memperbaik cacet: [ity te eto [Estatan Nove jdenikasi bagian mana pun untuk menemukan cacat yang dapat membaheyakan orang dan daekripal eacat Gita Uae |ceriicaton of any part to founda detect which is or could become a danger to persons and a description o the defect (i aone state NONE). ako the requirement to SE ee Diinspeksi Oren ‘Dverifikasi Oh, Disetujul oleh tt wn No Dok. PT. UNILEVER OLEOCHEMICHAL —_bDec.No LOC SHENG} ea INDONESIA eee | sayapr020 == | Unilever | CHECKLIST KENDARAAN RODA EMPAT fn" | oft Day/Date of inspection : O/ ~//- 202.2 Place of inspection 9 4a Contractor Name PT. PMB ‘A. DATA KEPEMILIKAN / DRIVER No Polisi/ Police Number bk F923 Ta 2. Merk/ pe Kendreon rota empat at y (Brand / type of four-wheeled vehicles) re ve iamee 3. Tahun pembuatan/ Production year acal 4 Nama Driver Utama/ Main Driver Name Rela Hadi yatto 5. Nama Driver Back up/ Bock up Driver Nome B. KELENGKAPAN ADMINISTRAS! (lingkari yang sesuai) 1 Sime Ada/Trdak ‘Masa beriaky: 3/ ~28- 2020 2 STNK* Ada/Treek Masaberlaku: 27 ~07 -2a26 3. KIR/KEUR Mobil Ada/ Tak Masaberiaku: 2p ~a?~ 2029 4. Sertifkat ODT! Ada/ Tek Masa beri 5. Sertifiat DDT! Ada/ Tidak Masa berlaku C. _KELENGKAPAN KENDARAAN 1 Rem [Brake + Propet/ Tidak Proper 2 Hand Break Hond reok Proper/ Tdeke Proper 3. Spion rearview mirror Proper! Tai Proper 4. Testilakson Test horn Proper/ TidaleBeaper 5. Gas 160: Proper/ TidetcProper 6 Kopling /Cutch Proper/ Tidal Proper 7. lampudepan —_/ the headlamps : Proper/ Fidat Proper 8B Lampusein turn signal + Proper/ Tidak Proper ‘9. Lampu rem J broke lights Proper/ Fidek-Proper 10. Lampu kabini/ cabin Lighting Proper/ Fidel Proper 21, Safety Bet Proper/ Tidak Proper 12, Banj Roda Cadangan Proper Haak Proper (— Yofe ~ Argan? bn cochey 13. Dongkrak dan Kunci (Tools) Proper/ Tidak-Proper 14, Kotak P3K Proper/ Tidak roner 15. APAR Proper/ Ytak Proper 16. Segitiga Pengaman + roper/ dake Broper 17. Window/ Wiper Proper/ Tidak Proper 18, Body Mobi Proper] Tidak Proper 19. Ganjalan ban/ Whell choke + Proper/ Tidak-Rroper 20. Kondisi Pity Mobil(Lengkap dengan Kunci) Proper] Tidak 2eaner 21. KondisiPintu Bak Mobil (Lengkap dengan Kunci) _: Proper/ Tidak Proper ‘Nb: Lampirkan foto kopi SIM, STNK, KIR, Record Maintenance pada saat inspeksi kendaroon. Inspectgd by, Drive 1 ‘Acknowledged, ] Sinatare Sanature = Siecaie |

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