Number: MS-0041015

Revision: 2
Management System Effective date:
Author:
2023 Jan 1
Filda Aisha
Template Approver: Mohammed Dkhissi
Process Owner: Holger Kunz

Test Request Form

APPLICANT
Company name: * PT. LONG RICH INDONESIA
Address: * JL. DI Panjaitan No, 8, Kel. Sidaresmi, Kec. Pabedilan, Kab. Cirebon, Jawa Barat (45193)
Tax number: Phone: +62 852-2166-8422
Contact person: Andry Iman Makbul Fax:
andry.makbul@mail.
Position: CSR Manager E-mail:
ymui-global.com
FINANCING (invoice to be sent) same as APPLICANT
Company name: * PT. LONG RICH INDONESIA
Address: * JL. DI Panjaitan No, 8, Kel. Sidaresmi, Kec. Pabedilan, Kab. Cirebon, Jawa Barat (45193)
Tax number: Phone: +62 852-2166-8422
Contact person: Andry Iman Makbul Fax:
andry.makbul@mail.y
Position: CSR Manager E-mail:
mui-global.com

DISCHARGE TYPE OF WASTE WATER*

☒ On-site zero liquid discharge (ZLD System)
☐ Direct discharged waste water with name of waterbody (river, pond, etc): …………………………………………………
☐ Indirect discharged without pre-treatment with name of centralized effluent plant: ………………………………………..
☐ Indirect discharged with pre-treatment with name of centralized effluent plant: ……………………………………………

AVERAGE TOTAL INDUSTRIAL WASTEWATER GENERATED*

☒ <15 m3 per day ☐ ≥15 m3 per day
SLUDGE DISPOSAL PATHWAY*
☒ A - Offsite Incineration at >1000oC ☐ E - Offsite Incineration and Building Products
☐ B - Landfill with Significant Control Measures Processed at <1000oC

☐ C - Building Products Processed at >1000oC ☐ F - Landfills with No Control Measures

☐ D - Landfill with Limited Control Measures ☐ G - Land Application

TEST REQUESTED*
☐ Full parameters according to Zero Discharge Hazardous Chemical Wastewater Guideline (ZDHC WWG V2.1)
☐ Individual test (please specify the test parameters):
☐ Table 1 (ZDHC MRSL Parameters): …………………………………………………………………………………………………
☐ Table 2 (ZDHC Heavy Metals Parameters): ………………………………………………………………………………………..
☐ Table 3 (ZDHC Conventional Parameters): ……………….………………………………………………………………………..
☒ Table 4 (ZDHC Sludge Parameters: …………………………………………………………………………………………………
☐ ZDHC Gateway Annual Reporting

☐ Others:      

Please ensure to include page 2 when submitting the signed TRF.

Date: *Authorized Signature and Company Stamp:

* The data marked with an asterisk need to be given in the same form as required on the test report. We request the above testing
and/or services and agree that all testing and/or services will be carried out subject to TUV Rheinland’s scale of charges and
turnaround times as set forth in the current price list at the time of testing and/or service delivery.

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