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Project Monitoring Action Report

PROJECT NAME : RDMP RU V BALIKPAPAN REPORT NO. : 402000-00540-CM-CHK-2957


CONTRACTOR : JO SHRP DATE : 02 February 2023

SECTION 1 OBSERVATION
: REPORT

DEPARTMENT : HSSE UNIT : U052_RFCC_Residued_Fluidized_Catalytic_Convertor

DISCIPLINE : Field Officer & Report SUB-UNIT : C052-25-26

IMPACTED : Safety Construction Schedule

No Category Compliance Severity Observation Recommendation


During monitoring ISBL area unit 052, for preparation installation coloumn C052-
25-26. one of subcontractor conduct really high risk behaviour for the working at
high activity. IPMT found around 6 workers at the top of the C052-25 without
100% tide off. the height of coloumn when the workers set up the accecories of
coloumn is 6,7meters. Workers wearing not inspect Full body harness, Step out
from Man lift, walking on the top of coloumn without any system fall protection
Working at DNC w/ install.
1 Critical Recommendation: Improvement
Height Procedure
JO SHRP have to ensure all workers following WAH Procedure Doc. No.: 26071-
100-GPP-GHX-00009 and Understanding how to implemented the procedure
with the daily activity. Need to refresh for worker WAH Training, and get deep
understanding how important to understand the standard of WAH. Fully
mitigation and risk assesment need to conduct before execute the job on site.

*Notes: Only one Category per PMAR - if two different categories, make a separate PMAR
Only one Unit per PMAR

SECTION 2 :REPORT PREPARATION AND REVIEW STATUS


DEPARTMENT: HSSE

PREPARED :
Name Rika Safutri Date: 02 February 2023
CHECKED 1 :
Name Jumri Date: 02 February 2023
CHECKED 2 :
Name Flocencio Ino Date: 02 February 2023
REVIEWED :

Name Sakti Puruboyo Date: 02 February 2023

SECTION 3 :FOLLOW UP ACTION (FILL-UP BY CONTRACTOR)

RESPONDED :
Name : Date:
VERIFIED :
Name : Date:

SECTION 4 :FOLLOW UP ACTION (FILL-UP BY IPMT)

VERIFIED
Name : Date:
SECTION 5 :ATTACHMENT(S) WITH DESCRIPTION (I.E PHOTOS, ETC)
Project Monitoring Action Report

PROJECT NAME : RDMP RU V BALIKPAPAN REPORT NO. : 402000-00540-CM-CHK-2964


CONTRACTOR : JO SHRP DATE : 28 January 2023

SECTION 1 : OBSERVATION REPORT

DEPARTMENT to action Construction UNIT : U321_Interconnecting_Pipe_Racks

DISCIPLINE : Civil SUB-UNIT :

IMPACTED : Safety Progress Delay

No Category Compliance Severity Observation Recommendation


During observation at U321 interconnecting foundation at area 45. IPMT found
excavation more than 2 m depth has not proper protected land sliding materials.
Found crack soil excavation at sloping this is high potential hit the workers when
working inside the excavation hole.

DNC w/ Recommendation:
1 Unsafe Condition High Contractors to ensure all trench excavations in excess of 4 ft. (1.2 m) depth shall Improvement
Procedure
be protected from collapse by the use of shoring, benching or cutting walls to a
stable slope and using tarpaulin or Geotech sheet to covering edge excavation
hole. Ensure the safety of workers by preventing landslide in excavation area, slope
or wood pile shall be provided. Refer to Doc. No. : 26071-000-GPP-GHX-00024
"Excavation & trenching Procedure

*Notes: Only one Category per PMAR - if two different categories, make a separate PMAR
Only one Unit per PMAR

SECTION 2 : REPORT PREPARATION AND REVIEW STATUS


DEPT. Issued by HSSE

PREPARED :
Name Jumri Nur Date: 28 January 2023
CHECKED 1 :
Name Jumri Nur Date: 28 January 2023
CHECKED 2 :
Name Lee Eagers Date: 28 January 2023
REVIEWED :
Name Sakti Puruboyo Date:

SECTION 3 : FOLLOW UP ACTION (FILL-UP BY CONTRACTOR)

RESPONDED :
Name : Date:
VERIFIED :
Name : Date:

SECTION 4 : FOLLOW UP ACTION (FILL-UP BY IPMT)

VERIFIED
Name : Date:

SECTION 5 : ATTACHMENT(S) WITH DESCRIPTION (I.E PHOTOS, ETC)


Project Monitoring Action Report

PROJECT NAME : RDMP RU V BALIKPAPAN REPORT NO. : 402000-00540-CM-CHK-3317


CONTRACTOR : JO SHRP DATE : 30 January 2023

SECTION 1 : OBSERVATION REPORT

DEPARTMENT to action :Construction UNIT : U052_RFCC_Residued_Fluidized_Catalytic_Convertor

DISCIPLINE : Civil SUB-UNIT :

IMPACTED : Safety Progress Delay

No Category Compliance Severity Observation Recommendation


During Observation at area U052 area 40, IPMT found generator at unsafe position
at field this is potential properly damage.

Recommendation:
1 Unsafe Condition Others Medium CONTRACTOR shall needs to be anticipation that any heavy rain for all working Improvement
areas too lower elevation and potential equipment to submerged in water and all
for supporting construction equipment need relocation with safe working areas.

*Notes: Only one Category per PMAR - if two different categories, make a separate PMAR
Only one Unit per PMAR

SECTION 2 : REPORT PREPARATION AND REVIEW STATUS


DEPT. Issued by HSSE

PREPARED :
Name Jumri Nur Date: 30 January 2023
CHECKED 1 :
Name Jumri Nur Date: 30 January 2023
CHECKED 2 :
Name Lee Eagers Date: 30 January 2023
REVIEWED :
Name Sakti Puruboyo Date:

SECTION 3 : FOLLOW UP ACTION (FILL-UP BY CONTRACTOR)

RESPONDED :
Name : Date:
VERIFIED :
Name : Date:

SECTION 4 : FOLLOW UP ACTION (FILL-UP BY IPMT)

VERIFIED
Name : Date:

SECTION 5 : ATTACHMENT(S) WITH DESCRIPTION (I.E PHOTOS, ETC)


Project Monitoring Action Report

PROJECT NAME : RDMP RU V BALIKPAPAN REPORT NO. : 402000-00540-CM-CHK- 3324


CONTRACTOR : JO SHRP DATE : 31 January 2023

SECTION 1 OBSERVATION
: REPORT

DEPARTMENT : Construction UNIT : U321_Interconnecting_Pipe_Racks

DISCIPLINE : Scaffolding SUB-UNIT :


IMPACTED : Safety Construction

No Category Compliance Severity Observation Recommendation


During monitoring and observation at pipe rack 331 near to EDG , there
is dismantling of scaffolding without stairs or access, it is high risk when
transferring the scaffold to another scaffolder that material may fall.
Main Cause : JO SHRP has failed to enforce subcontractor to fulfill
scaffolding procedure on site.
Recommendation: Follow Doc. no. 26071-100-GPP-GHX-00021-001
Working at DNC w/ Scaffolding Procedure. The scaffold plan shall contain as follows:
1 High Improvement
Height Procedure material selection, general design, basis of design, foundations
(including ground conditions and loadings), supporting structure, stability,
tying, working platform, planks, access egress and edge protection,
and ladder . provide safe access/ladder when dismantling scaffolding
and availability of access/ladder in case of emergency. JO must do
safety assessment to mitigate hazards for scaffolding dismantling.
Conduct briefing and share the Scaffolding procdure to workers ASAP.
*Notes: Only one Category per PMAR - if two different categories, make a separate PMAR
Only one Unit per PMAR

SECTION 2 R
: EPORT PREPARATION AND REVIEW STATUS
DEPARTMENT: HSSE

PREPARED :

Name Date: 31 January 2023


Gibson Damanik
CHECKED 1 :
Jan 31, 2023 | 12:40:09 SEAST

Name Date: 31 January 2023

Airlangga Putra
CHECKED 2 :

Name Date: 31 January 2023

David Webb
REVIEWED :

Name Date:
Sakti Puruboyo
SECTION 3 F
: OLLOW UP ACTION (FILL-UP BY CONTRACTOR)

RESPONDED :

Name : Date:

VERIFIED :

Name : Date:
SECTION 4 F
: OLLOW UP ACTION (FILL-UP BY IPMT)
VERIFIED

Name : Date:

SECTION 5 A
: TTACHMENT(S) WITH DESCRIPTION (I.E PHOTOS, ETC)
Project Monitoring Action Report

PROJECT NAME : RDMP RU V BALIKPAPAN REPORT NO. : 402000-00540-CM-CHK-3326


CONTRACTOR : JO SHRP DATE : 31 January 2023

SECTION 1 OBSERVATION
: REPORT

DEPARTMENT : Construction UNIT : U059_CCR_Platforming

DISCIPLINE : Civil SUB-UNIT : 059F01 .

IMPACTED : Safety Construction Quality

No Category Compliance Severity Observation Recommendation


During site assessment and surveillance of Unit 059 (CCR) area 44 ISBL on 30
January 2023, we found :

- Contractor (JO-SHRP) failed to control, and manage poor lifting


implementation on site, no rigger and signalman during lifting rebar activity. JO
Construction, and the HSSE team (JO-SHRP) must close monitoring and total
control and apply the procedure running correctly.

Contractor is required to comply and follow up.

- Based on Document Management, Review, and Approval Procedure, Follow


the required Procedure (please see the details below) and need to expedite
DNC w/ action by the relevant Department.
1 Cranes & Lifting High Reject
Procedure - STOP Lifting activity if incomplete procedure on-site
- Refresh lifting training and re-socialization for Supervisor and related team and
close the issue in 3 days
- 26071-100-G01-GHX-00002 Rev.002 PROJECT HSE PLAN
- 26071-100-GPP-GCX-00001 Rev.001 CONSTRUCTION EXECUTION PLAN
- 26071-100-GPP-GHX-00011 Rev.000 Crane and Lifting Operation
Procedure

#Area 44 U059 JO Construction

*Notes: Only one Category per PMAR - if two different categories, make a separate PMAR
Only one Unit per PMAR

SECTION 2 R
: EPORT PREPARATION AND REVIEW STATUS
DEPARTMENT: HSSE

PREPARED : Jan 31, 2023 | 16:47:56 AEDT


Name ASBUDILLAH Date:
CHECKED 1 :
Jan 31, 2023 | 19:58:54 AEDT
Name JUMRI Date:
CHECKED 2 :
Name LEE EAGERS Date:
Feb 2, 2023 | 11:51:25 AEDT
REVIEWED :
Name Date:

SECTION 3 F
: OLLOW UP ACTION (FILL-UP BY CONTRACTOR)

RESPONDED :
Name : Date:
VERIFIED :
Name : Date:

SECTION 4 F
: OLLOW UP ACTION (FILL-UP BY IPMT)

VERIFIED
Name : Date:
SECTION 5 A
: TTACHMENT(S) WITH DESCRIPTION (I.E PHOTOS, ETC)

No rigger and signalman during lifting rebar activity


Project Monitoring Action Report

PROJECT NAME : RDMP RU V BALIKPAPAN REPORT NO. : 402000-00540-CM-CHK- 3331


CONTRACTOR : JO SHRP DATE : 31 January 2023

SECTION 1 OBSERVATION
: REPORT

DEPARTMENT : Construction UNIT : U321_Interconnecting_Pipe_Racks

DISCIPLINE : Scaffolding SUB-UNIT :


IMPACTED : Safety Construction

No Category Compliance Severity Observation Recommendation


During monitoring and observation at pipe rack around GTG, found that
some scaffolding ladders without inspection tags.
Main Cause : JO SHRP has failed to enforce subcontractor to fulfill
scaffolding procedure on site.

Working at DNC w/ Recommendation: Follow Doc. no. 26071-100-GPP-GHX-00021-001


1 High Scaffolding Procedure. Scaffolders must attach to the first lift of scaffold Reject
Height Procedure
a Red Tag Holder which reads ‘DO NOT USE SCAFFOLD’. Scaffolds will
be re-inspected every week, or after bad weather. A thorough check of
foundations is also to be made. The person doing the inspection of the
scaffold will record the date and their signature on the back of the Green
Tag after each inspection. Inspection tag mus be available (red or green)
*Notes: Only one Category per PMAR - if two different categories, make a separate PMAR
Only one Unit per PMAR

SECTION 2 R
: EPORT PREPARATION AND REVIEW STATUS
DEPARTMENT: HSSE

PREPARED :

Name Date: 31 January 2023


Gibson Damanik
CHECKED 1 : Jan 31, 2023 | 13:01:39 SEAST

Name Date: 31 January 2023


Airlangga Putra
CHECKED 2 :

Name Date: 31 January 2023

David Webb
REVIEWED :

Name Date:
Sakti Puruboyo
SECTION 3 F
: OLLOW UP ACTION (FILL-UP BY CONTRACTOR)

RESPONDED :

Name : Date:

VERIFIED :

Name : Date:

SECTION 4 F
: OLLOW UP ACTION (FILL-UP BY IPMT)
VERIFIED

Name : Date:
SECTION 5 A
: TTACHMENT(S) WITH DESCRIPTION (I.E PHOTOS, ETC)
DocuSign Envelope ID: E572D882-E0C5-4724-B044-8884C42B484C

Project Monitoring Action Report

PROJECT NAME : RDMP RU V BALIKPAPAN REPORT NO. : 402000-00540-CM-CHK-3343


CONTRACTOR : JO SHRP DATE : 31 January 2023

SECTION 1 OBSERVATION
: REPORT

DEPARTMENT : Construction UNIT : U052_RFCC_Residued_Fluidized_Catalytic_Convertor

DISCIPLINE : Civil SUB-UNIT : PR-052-01

IMPACTED : Safety Construction

No Category Compliance Severity Observation Recommendation

Contractor has failed to enforce proper implementation Doc. No.: 26071- 100-
GPP-GHX-00006-000 - Electrical Equipment and Assured Grounding
Procedure, during observation underneath piperack PR-052-01 found poor
cable management. electrical cable power laying down above wet ground, it will
DNC w/ be potential hazard if any failure electric current
1 Electrical High Recommendation:
Improvement
Procedure
- Crossing live electric cable should be above wet ground/soil in case of any
failure leak
- Ensure electric cable not directly contact with wet ground/soil by install cable
support.

*Notes: Only one Category per PMAR - if two different categories, make a separate PMAR
Only one Unit per PMAR

SECTION 2 :REPORT PREPARATION AND REVIEW STATUS


DEPARTMENT: HSSE

PREPARED :
Name Heru Rusadi Date: 31 January 2023
CHECKED 1 :
Jumri M Nur
Jan 31, 2023 | 17:32:36 AEDT
Name Date:
CHECKED 2 :
Jan 31, 2023 | 19:07:13 AEDT
Name Florencino D. Ino Date:
REVIEWED :

Name Sakti Puruboyo Date:

SECTION 3 :FOLLOW UP ACTION (FILL-UP BY CONTRACTOR)

RESPONDED :
Name : Date:
VERIFIED :
Name : Date:

SECTION 4 :FOLLOW UP ACTION (FILL-UP BY IPMT)

VERIFIED
Name : Date:

SECTION 5 :ATTACHMENT(S) WITH DESCRIPTION (I.E PHOTOS, ETC)


Project Monitoring Action Report

PROJECT NAME : RDMP RU V BALIKPAPAN REPORT NO. : 402000-00540-CM-CHK-3347


CONTRACTOR : JO SHRP DATE : 31 January 2023

SECTION 1 : OBSERVATION REPORT

DEPARTMENT to action : Construction UNIT : U052_RFCC_Residued_Fluidized_Catalytic_Convertor

DISCIPLINE : Mechanical - General SUB-UNIT :

IMPACTED : Safety Progress Delay

No Category Compliance Severity Observation Recommendation


During Observation at area U052 area 40, IPMT found temporary timber support
saddle for flue gas line serial No. SN-052-095-6 at unsafe and unstable position
this is potential fell down.

Recommendation:
1 Unsafe Condition Others Medium CONTRACTOR shall needs to be add support and barricade tape to restricted
Improvement
around area. For preventing the incident happen. JO SHRP manterial control
team to conduct inspection for all material after receiving or long time delivery to
the site.

*Notes: Only one Category per PMAR - if two different categories, make a separate PMAR
Only one Unit per PMAR

SECTION 2 : REPORT PREPARATION AND REVIEW STATUS


DEPT. Issued by HSSE

PREPARED :
Name Jumri Nur Date: 31 January 2023
CHECKED 1 :
Name Jumri Nur Date: 31 January 2023
CHECKED 2 :
Name Ino Florencio Date: 31 January 2023
REVIEWED :
Name Sakti Puruboyo Date:

SECTION 3 : FOLLOW UP ACTION (FILL-UP BY CONTRACTOR)

RESPONDED :
Name : Date:
VERIFIED :
Name : Date:

SECTION 4 : FOLLOW UP ACTION (FILL-UP BY IPMT)

VERIFIED
Name : Date:

SECTION 5 : ATTACHMENT(S) WITH DESCRIPTION (I.E PHOTOS, ETC)


Project Monitoring Action Report

PROJECT NAME : RDMP RU V BALIKPAPAN REPORT NO. : 402000-00540-CM-CHK- 3356


CONTRACTOR : JO SHRP DATE : 01 February 2023

SECTION 1 OBSERVATION
: REPORT

DEPARTMENT : Construction UNIT : U321_Interconnecting_Pipe_Racks

DISCIPLINE : Scaffolding SUB-UNIT :


IMPACTED : Safety Construction

No Category Compliance Severity Observation Recommendation


During monitoring and observation at pipe rack R10 - Area 15, found that
scaffolder was installing scaffolding by standing on the pipe and no safe
access.
Main Cause : JO SHRP has failed to enforce subcontractor to fulfill
scaffolding procedure on site.
Recommendation: Follow Doc. no. 26071-100-GPP-GHX-00021-001
Working at DNC w/
1 High Scaffolding Procedure. Workers must be provided with safe access to Perform TBT
Height Procedure
and egress from scaffold during the erection, use and dismantling of
scaffolding. Common means of access and egress include: temporary
stairs or portable ladder access systems installed at the start of erection,
whenever possible. Install temporary platform as foot stand when to
extend height of scaffolding. Stand to scaffolding pipe are prohibited.
"Conduct refresh training related to Scaffolding procedure."
*Notes: Only one Category per PMAR - if two different categories, make a separate PMAR
Only one Unit per PMAR

SECTION 2 R
: EPORT PREPARATION AND REVIEW STATUS
DEPARTMENT: HSSE

PREPARED :

Name Date: 01 February 2023


Gibson Damanik
CHECKED 1 :
Feb 2, 2023 | 12:52:11 SEAST

Name Date: 01 February 2023

Airlangga Putra
CHECKED 2 :
Feb 2, 2023 | 19:28:02 AEDT
Name Date: 01 February 2023

David Webb
REVIEWED :

Name Date:
Sakti Puruboyo
SECTION 3 F
: OLLOW UP ACTION (FILL-UP BY CONTRACTOR)

RESPONDED :

Name : Date:

VERIFIED :

Name : Date:

SECTION 4 F
: OLLOW UP ACTION (FILL-UP BY IPMT)
VERIFIED

Name : Date:

SECTION 5 A
: TTACHMENT(S) WITH DESCRIPTION (I.E PHOTOS, ETC)
Project Monitoring Action Report

PROJECT NAME : RDMP RU V BALIKPAPAN REPORT NO. : 402000-00540-CM-CHK-3368


CONTRACTOR : JO SHRP DATE : 01 February 2023

SECTION 1 : OBSERVATION REPORT

DEPARTMENT to action : Construction UNIT : U052_RFCC_Residued_Fluidized_Catalytic_Convertor

DISCIPLINE : Civil SUB-UNIT :

IMPACTED : Safety Progress Delay

No Category Compliance Severity Observation Recommendation


During Observation at U052 area 40, Road 535, IPMT found drainage blocked by
soil, drainage system not function.

1 Environment Others Medium Recommendation: Improvement


CONTRACTOR shall need rebuild the drainage system along roads (Jln. 535)
and JO SHRP to maintain and remove soil inside the U-ditch existing drainage.

*Notes: Only one Category per PMAR - if two different categories, make a separate PMAR
Only one Unit per PMAR

SECTION 2 : REPORT PREPARATION AND REVIEW STATUS


DEPT. Issued by HSSE

PREPARED :
Name Jumri Nur Date: 01 February 2023
CHECKED 1 :
Name Jumri Nur Date: 01 February 2023
CHECKED 2 :
Name Ino Florencio Date: 01 February 2023
REVIEWED :
Name Sakti Puruboyo Date:

SECTION 3 : FOLLOW UP ACTION (FILL-UP BY CONTRACTOR)

RESPONDED :
Name : Date:
VERIFIED :
Name : Date:

SECTION 4 : FOLLOW UP ACTION (FILL-UP BY IPMT)

VERIFIED
Name : Date:

SECTION 5 : ATTACHMENT(S) WITH DESCRIPTION (I.E PHOTOS, ETC)


Project Monitoring Action Report

PROJECT NAME : RDMP RU V BALIKPAPAN REPORT NO. : 402000-00540-CM-CHK- 3371


CONTRACTOR : JO SHRP DATE : 02 February 2023

SECTION 1 OBSERVATION
: REPORT

DEPARTMENT : Construction UNIT : U319_Flare_System_Including_Acid_Flare

DISCIPLINE : Marine SUB-UNIT : RFCC Flare Equipment


IMPACTED : Safety Construction

No Category Compliance Severity Observation Recommendation


During monitoring and observation at Jetty 7A - Flare area by PT. PDP,
found that the crane`s inspection sticker was already expired. Base on
information that there`s abnormality from load chart display versus actual
degree or Indicators must be SATISFACTORY.
Main Cause : JO SHRP has failed to force subcontractors to comply with
safety standards on crane and JO failed to stop crane not to operate
DNC w/
1 Cranes & Lifting Critical abnormal cranes for daily lifting. Repair
Procedure
Recommendation: Follow Doc. no. 26071-100-GPP-GHX-00026-000
RDMP JO / Subcontractor will tag any tool/equipment that fails the
inspection criteria with an “Out of Service” tag, which shall be marked
with details of the defect. Need to repair or callibration the indicator soon.
Stop crane when any abnormal indicator or inspection tag is still not
updated refer to current coding (blue).
*Notes: Only one Category per PMAR - if two different categories, make a separate PMAR
Only one Unit per PMAR

SECTION 2 R
: EPORT PREPARATION AND REVIEW STATUS
DEPARTMENT: HSSE

PREPARED :

Name Date: 02 February 2023


Gibson Damanik
CHECKED 1 :
Feb 2, 2023 | 12:47:38 SEAST

Name Date: 02 February 2023

Airlangga Putra
CHECKED 2 :

Name Date: 02 February 2023

Edwin Carpio
REVIEWED :

Name Date:
Sakti Puruboyo
SECTION 3 F
: OLLOW UP ACTION (FILL-UP BY CONTRACTOR)

RESPONDED :

Name : Date:

VERIFIED :

Name : Date:

SECTION 4 F
: OLLOW UP ACTION (FILL-UP BY IPMT)
VERIFIED

Name : Date:

SECTION 5 A
: TTACHMENT(S) WITH DESCRIPTION (I.E PHOTOS, ETC)
Project Monitoring Action Report

PROJECT NAME : RDMP RU V BALIKPAPAN REPORT NO. : 402000-00540-CM-CHK-3382


CONTRACTOR : JO SHRP DATE : 02 February 2023

SECTION 1 : OBSERVATION REPORT

DEPARTMENT to action : Construction UNIT : U054_Diesel_Hydrotreating_Unit_I

DISCIPLINE : Civil SUB-UNIT :

IMPACTED : Safety Progress Delay

No Category Compliance Severity Observation Recommendation


During observation at U054 interconnecting foundation at area 27. IPMT found
excavation more than 2 m depth has not proper protected land sliding materials.
Found concrete box and found crack soil excavation at sloping this is high
potential hit the workers when working inside the excavation hole.

Recommendation:
DNC w/ Contractors to ensure all trench excavations in excess of 4 ft. (1.2 m) depth shall
1 Unsafe Condition High be protected from collapse by the use of shoring, benching or cutting walls to a Improvement
Procedure
stable slope and using tarpaulin or Geotech sheet to covering edge excavation
hole. Ensure the safety of workers by preventing landslide in excavation area,
slope or wood pile shall be provided. Refer to Doc. No. : 26071-000-GPP-GHX-
00024 "Excavation & trenching Procedure

*Notes: Only one Category per PMAR - if two different categories, make a separate PMAR
Only one Unit per PMAR

SECTION 2 : REPORT PREPARATION AND REVIEW STATUS


DEPT. Issued by HSSE

PREPARED :
Name Jumri Nur Date: 02 February 2023
CHECKED 1 :
Name Jumri Nur Date: 02 February 2023
CHECKED 2 :
Name Ino Florencio Date: 02 February 2023
REVIEWED :
Name Sakti Puruboyo Date:

SECTION 3 : FOLLOW UP ACTION (FILL-UP BY CONTRACTOR)

RESPONDED :
Name : Date:
VERIFIED :
Name : Date:

SECTION 4 : FOLLOW UP ACTION (FILL-UP BY IPMT)

VERIFIED
Name : Date:

SECTION 5 : ATTACHMENT(S) WITH DESCRIPTION (I.E PHOTOS, ETC)

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