Service 

Report
Berita Acara
Report to Customer
Rentokil Indonesia (RI-JK-OS-230-SE-F-8.5-06)
Ref:142143_20230303200724
A. CUSTOMER INFORMATION
Purpose of Treatment Routine Shared Type of Premise Hospitals
Account Number 700022169 Type of Pests Covered Qty Freq
Contract Number 50051177/1 Lumnia B
9 12
: (LMNIAB)
Type of Premise Hospitals
General Pest Plus
Customer Name RS SEPATAN MULIA : Ants - Other, Cockroaches - Other, Flies, Mosquito, Rodents 0 48
Contact Name IBU NOVA (GPP)
Cat Control
Contact Number +622159371801 0 48
: (CATC)
Address (Site of application) RS SEPATAN MULIA
Fogging (Oil Based)
JL. RAYA PAKUHAJI RT 02 RW 0 48
: (FOG)
01
SEPATAN
TANGERANG
BANTEN
15520
Site Risk Assessment
Terdapat Anak-anak/Orang Tua/Orang Cacat/Keramaian : AREA DALAM Terdapat kendaraan/forklift/mesin pengangkat : PARKIR Bahan kimia/gas/debu/uap
: AREA LUAR, AREA DALAM Mengangkat/mengangkut : AREA LUAR, AREA DALAM Adanya penghisap udara pada sistem ventilasi : AREA DALAM

B. APPLICATOR’S INFORMATION C. CUSTOMER’S SIGNATURE/COMPANY STAMP
I declare the information below is true and
I acknowledge receipt of the report below:
correct:
Signature: Signature:

FIKRI BAMBANG IRAWAN

Name Name bp hairudi
FIKRI BAMBANG IRAWAN
License No. Date 03-03-2023 10:05
Date 03-03-2023 10:05
Time In 10:05
Time Out 20:07
Name of other Applicators: DEBY ISWANTO DEBY ISWANTO

D. PESTICIDES APPLIED
Active Ingredient Trade Name Class Method of Total Area Total
(Conc. Diluted Solution Applied (%)) (Conc. Diluted Solution Applied (%)) Application Treated Qty Used

Luminos 1 Glue 011 (LMNIAB) Monitoring / Trapping 9 Unit

Area Pesticide Applied

Lem Tikus Tube (GPP) Monitoring / Trapping 4 Tube

Area Pesticide Applied

Cypermethrin Smash 100EC (GPP) Cold fogging 100 ml

Area Pesticide Applied

Cypermethrin Smash 100EC (GPP) Spraying 100 ml

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 Area Pesticide Applied

Brodifacoum Talon 0.005 BB (GPP) Baiting 120 gram

Area Pesticide Applied

Cypermethrin Smash 100EC (FOG) Thermal fogging 100 ml

Area Pesticide Applied

Brodifacoum Talon 0.005 BB (GPP) Baiting 8 gram

Area Pesticide Applied

Brodifacoum Talon 0.005 BB (GPP) Baiting 8 gram

Area Pesticide Applied

Lem Tikus Tube (GPP) Monitoring / Trapping 0.25 Tube

Area Pesticide Applied

Lem Tikus Tube (GPP) Monitoring / Trapping 0.25 Tube

Area Pesticide Applied

Luminos 1 Glue 011 (LMNIAB) Monitoring / Trapping 1 Unit

Area Pesticide Applied

Luminos 1 Glue 011 (LMNIAB) Monitoring / Trapping 1 Unit

Area Pesticide Applied

Luminos 1 Glue 011 (LMNIAB) Monitoring / Trapping 1 Unit

Area Pesticide Applied

Luminos 1 Glue 011 (LMNIAB) Monitoring / Trapping 1 Unit

Area Pesticide Applied

Luminos 1 Glue 011 (LMNIAB) Monitoring / Trapping 1 Unit

Area Pesticide Applied

Luminos 1 Glue 011 (LMNIAB) Monitoring / Trapping 1 Unit

Area Pesticide Applied

Cypermethrin Smash 100EC (GPP) Spraying 100 ml

Area Pesticide Applied

Cypermethrin Smash 100EC (FOG) Thermal fogging 100 ml

Area Pesticide Applied

Cypermethrin Smash 100EC (GPP) Cold fogging 100 ml

Area Pesticide Applied

E. PEST STATUS
Pest Level Location Found Remarks

Flying Insect Other Low - 10 Internal

Building: RS SEPATAN MULIA, Floor: 1st Floor, Zone: 3rd Line Office, Location Found: I4. 1 LUMNIA

Houseflies Low - 2 Internal

Building: RS SEPATAN MULIA, Floor: 1st Floor, Zone: 3rd Line Office, Location Found: I4. 1 LUMNIA

Mosquito Low - 4 Internal

Building: RS SEPATAN MULIA, Floor: 1st Floor, Zone: 3rd Line Office, Location Found: I4. 1 LUMNIA

Flying Insect Other Low - 6 Internal

Building: RS SEPATAN MULIA, Floor: 1st Floor, Zone: 3rd Line Office, Location Found: I4. 2 LUMNIA

Houseflies Low - 1 Internal

Building: RS SEPATAN MULIA, Floor: 1st Floor, Zone: 3rd Line Office, Location Found: I4. 2 LUMNIA

Flying Insect Other Medium - 27 Internal

Building: RS SEPATAN MULIA, Floor: 1st Floor, Zone: 3rd Line Office, Location Found: I4. 5 LUMNIA

Houseflies Low - 8 Internal

Building: RS SEPATAN MULIA, Floor: 1st Floor, Zone: 3rd Line Office, Location Found: I4. 5 LUMNIA

Mosquito Low - 18 Internal

Building: RS SEPATAN MULIA, Floor: 1st Floor, Zone: 3rd Line Office, Location Found: I4. 5 LUMNIA

Flying Insect Other Medium - 28 Internal

Building: RS SEPATAN MULIA, Floor: 1st Floor, Zone: 3rd Line Office, Location Found: I4. 4 LUMNIA
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 Houseflies Low - 5 Internal
Building: RS SEPATAN MULIA, Floor: 1st Floor, Zone: 3rd Line Office, Location Found: I4. 4 LUMNIA

Mosquito Low - 10 Internal

Building: RS SEPATAN MULIA, Floor: 1st Floor, Zone: 3rd Line Office, Location Found: I4. 4 LUMNIA

Flying Insect Other Low - 6 Internal

Building: RS SEPATAN MULIA, Floor: 1st Floor, Zone: 3rd Line Office, Location Found: I4. 3 LUMNIA

Houseflies Low - 2 Internal

Building: RS SEPATAN MULIA, Floor: 1st Floor, Zone: 3rd Line Office, Location Found: I4. 3 LUMNIA

Mosquito Low - 7 Internal

Building: RS SEPATAN MULIA, Floor: 1st Floor, Zone: 3rd Line Office, Location Found: I4. 3 LUMNIA

Flying Insect Other Medium - 27 Internal

Building: RS SEPATAN MULIA, Floor: 1st Floor, Zone: 3rd Line Office, Location Found: I4. 6 LUMNIA

Houseflies Low - 6 Internal

Building: RS SEPATAN MULIA, Floor: 1st Floor, Zone: 3rd Line Office, Location Found: I4. 6 LUMNIA

Mosquito Low - 19 Internal

Building: RS SEPATAN MULIA, Floor: 1st Floor, Zone: 3rd Line Office, Location Found: I4. 6 LUMNIA

F. RECOMMENDATIONS BY RENTOKIL INITIAL
Type Recommendations Priority
(GPP) Tumpukkan barang yang diletakkan dekat dengan bangunan akan dijadikan sebagai sarang oleh hama,
Stacking pastikan untuk meniadakan tumpukkan barang tersebut atau direlokasi jauh dari bangunan.sisa paping blok yang Low
tidak tersusun yang berada di sisi pagar,mohon untuk paping blok d jadikan satu

G. SERVICE VISIT NOTES
Product (s) Visit Notes

Cat Control - 48

Fogging (Oil Based) - 48

Lumnia B - 12

General Pest Plus - 48

Rentokil Indonesia Komplek Pergudangan Multiguna, Duta Indah Iconic, Blok C No.37, Jl. M H Thamrin, Cikokol, Tangerang, 15117
t +622129866707/706 f e rendra.wdriyo@rentokil-initial.com w www.rentokil.co.id p myRentokil

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