No.

REPUBLIC OF INDONESIA
MINISTRY OF AGRICULTURE
KT - 10 INDONESIAN AGRICULTURAL QUARANTINE AGENCY

PHYTOSANITARY CERTIFICATE Plant Protection Organization of Indonesia

No.: .D...R...A....F..T....D...R....A...F...T........................ to: Plant Protection Organization(s) of.
.V I E T N A M.............................................................
I. DESCRIPTION OF CONSIGNMENT
Name and address of exporter: Declared name and address of consignee:
PT. OLAM INDONESIA CAFE OUTSPAN VIETNAM LTD
SOUTH QUARTER TOWER A, LANTAI 21, UNIT A,G,H LOT L1, NHUT CHANH INDUSTRIAL PARK, NHUT CHANH
JL.R.A KARTINI KAV. 8 JAKARTA SELATAN, INDONESIA COMMUNE, BEN LUC DIST, LONG AN PROVINCE, VIETNAM
TEL : 84 272 3655999 – FAX : 84 272 3655986

Declared means of conveyance: Declared point of entry:

BG. SEJAHTERA 3032 10/23B HO CHI MINH, VIETNAM

HS Code: Place of Origin:

090111 PANJANG, INDONESIA

Distinguishing marks: Number and description of packages, name of produce, Quantity Declared:
OLAM COFFEE botanical name of plants:
ROBUSTA OF INDONESIA 1. IN 2400 BAGS GROSS WEIGHT : 145,920.00 KGS NETT 144,000.00
WEIGHT : 144,000 KGS kilograms
INDONESIA ROBUSTA COFFEE BLACK BEANS
Coffea spp Total: 144,000.00
Number of Commodities: 1 kilograms

II. ADDITIONAL DECLARATION III. DISINFESTATION AND/OR DISINFECTION TREATMENT

BL NUMBER : Treatment Date
EGLV083300000778 === NONE === === NONE ===

Chemical (active ingredient) Concentration

=== NONE === === NONE ===

Duration and Temperature

=== NONE ===

Additional Information
=== NONE ===

This is to certify that the plants or plant products or other regulated articles described herein:
- have been inspected and/or tested according to appropriate official procedures and
- are considered to be free from the quarantine pests specified by the importing contracting party and
- to conform with the current phytosanitary requirements of the importing contracting party, including those for
regulated non-quarantine pests.

Name of
authorized officer:
Place of issue: BANDAR LAMPUNG

Date of issue: March , 2023

(Signature) (Stamp of Organization)
No financial liability with respect to this certificate shall attach to Plant Quarantine Service of Indonesia or to any of its officers or
representatives.

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