Form PunchList

Air Separation Unit (ASU) Project
2A Hernadi 1-Sept- Agung R. 1-Sep-2022 Riky Novfriska 1-Sep-2022 Issued for Construction

2022
1A Hernadi 22-Aug- Agung R. 22-Aug-2022 Riky Novfriska 22-Aug-2022 Issued for Approval
2022
Name Date Name Date Name Date
Rev Document Type
Prepared by Reviewed by Approved by
PROJECT Air Separation Unit (ASU) Project
OWNER PT AMMAN Mineral Industri
PMC TATA Consulting Engineers Limited
CONTRACTOR PT JGC Indonesia
SUB CONTRACTOR
Document Title Site Inspection Test Plan For Building

Document ID ACCS-40-411-AS01-S-PLN-0201 Rev
Sheet 1
All rights reserved, no part of this document may be reproduced or transmitted in any form or by any means without the prior permission in writing from PT. JGC
Indonesia.
1/1
Construction
r Approval
ument Type
ted
2A
OF 6
1 / 103
Document AMIN ID ACCS-40-411-AS01-S-PLN-0201
Document JIND ID S-A000-1670-201
Date 1-Sept-2022 Rev 2A
Sheet 2 OF 6
PT. JGC INDONESIA
Name Signature Date
Prepared by: Hernadi 1 September 2022
Reviewed by: Agung R. 1 September 2022
Approved by: Riky Novfriska 1 September 2022
PMC/AMIN
Name Position Signature Date
CODES
(A) Approved.Proceed with Fabrication/Construction (D) Returned without review, reasons as enclosed /
marked. Work shall not proceed.
Approved with comments. Proceed with Documents retained for information only.
Fabrication/Construction incorporating our comments
(B) and resubmit for final (E)
approval.
Commented. Document to be resubmitted for approval
incorporating our comments. Work shall not proceed.
(C)
Only valid when sealed

with the technical stamp of
PT. JGC Indonesia
Date
1 September 2022
1 September 2022
1 September 2022
Date
review, reasons as enclosed /

all not proceed.
ed for information only.

Sheet 3 OF 6
Revision List Table
No Date Revision Page Description Remarks

1 22-Aug-2022 1A All Issued for Approval
1 1-Sep-2022 2A All Issued for Construction
Sheet 4 OF 6
TABLE OF CONTENTREVISION LIST TABLE 31.
31. GENERAL
Sheet 5 OF 6
1. GENERAL
PT Amman Mineral Industri (AMIN) is in the process of setting up a Captive Copper Smelter Project with capacity 900 KTPA copper
concentrate at Sumbawa Island, West Nusa Tenggara, Indonesia. The smelter product will be 222 KTPA of copper cathode with purity
99.99% Cu and 830 KTPA sulfuric acid with purity 98.5%.
For Copper smelter will require a continuous supply of Oxygen & Nitrogen gases. Therefore, it is proposed to have a dedicated Air
Separation Unit (ASU) for uninterrupted supply of oxygen & nitrogen gases.
This document is intended to provide Site Inspection and Test Item for Building Works to be required during construction stage for
Air Separation Unit (ASU) Project. The inspection and test item provided in this document includes intervention of ‘Witness’. ‘Spo
Witness’, ‘Review’, or ‘Hold’ points of each party involved in the inspection and test, i.e: SUBCONTRACTOR, CONTRACTOR,
OWNER.
2. DEFINITION & ABBREVIATION
PROJECT Air Separation Unit (ASU) Project
OWNER PT. Amman Mineral Industri
CONTRACTOR PT JGC Indonesia
SUBCONTRACTOR Any organization who provides service of construction/installation of
equipment and material for the project.
3. REFERENCE DOCUMENT
JIND Document No. AMIN Document No. Document Title
S-A000-1340-001 ACCS-40-411-AS01-G-SPC-0001 GENERAL SPECIFICATION FOR

BUILDING
S-A000-1520-001 ACCS-40-411-AS01-Q-PLN-0001 QC EXECUTION PLAN
S-A000-1520-006 ACCS-40-411-AS01-Q-SPC-0006 NON-CONFORMITY CONTROL
PROCEDURE
QUALITY CONTROL
S-A000-1670-001 ACCS-40-411-AS01-Q-SPC-0008 REQUIREMENTS TO
SUBCONTRACTOR.
4. RESPONSIBILITIES
SUBCONTRACOTR shall be responsible to prepare and submit Inspection & Test Plan (ITP) related to their scope of work to
CONTRACTOR for review and approval prior to commence the construction / installation work.
CONTRACTOR shall be responsible to review and approve the ITP submitted by SUBCONTRACTOR. When required by contract,
SUBCONTRACTOR’s ITP shall also be reviewed and approved by OWNER.
5. PROCEDURES
5.1 General Requirement
As required by Contract, each SUBCONTRACTOR shall prepare the ITP (Inspection and Test Plan) with refer to this procedure and item
as shown in Attachment-1: Inspection and Test Plan Items.
Determination of intervention point of SUBCONTRACTOR, CONTRACTOR and OWNER, shall be discussed and establish
during Pre-Inspection Meeting (PIM) or Kick of Meeting (KOM)
The following letters and abbreviations are to be used in the Inspection and Test Plan:
H (Hold Point)
pacity 900 KTPA copper
opper cathode with purity
o have a dedicated Air
uring construction stage for

ervention of ‘Witness’. ‘Spot
ACTOR, CONTRACTOR,
FOR
TROL
TROL
TO
scope of work to
en required by contract,
er to this procedure and items
l be discussed and established

Sheet 6 OF 6
Intervention point shall align with QC requirement to Subcontractor S-A000-1670-001 Attachment-1
W (Witness Point)
CONTRACTOR / COMPANY intends to witness the test/inspection, however SUBCONTRACTOR can proceed with the test /
inspection when the CONTRACTOR inspector is not present at the notified time. SUBCONTRACTOR shall submit inspection
notification to CONTRACTOR.
SW (Spot Witness)
Spot witness specified the operation test / examination where the CONTRACTOR’s Inspector must be notified in advance and may
present during the specified activity. SUBCONTRACTOR shall submit inspection notification to CONTRACTOR.
R (Record Review)
Record and/or document review.
Subcontractor shall provide CONTRACTOR with certificates, reports and records as applicable for review and approval.
M (Implementation)
Preparation and execution of inspection by measurement, observation, examination and / or testing include reporting.
5.2 Inspection and Test Item

Inspection and test item includes its intervention point of each party for each work category required during construction stage of project
execution at site is given in Attachment-1: Site Inspection and Test Item.
Inspection and test item specified in this document comprise the following work categories:
(1) EXTERIOR & INTERIOR WORKS
(2) PLUMBING WORK
(3) FIRE FIGTHING WORK
(4) ELECTRICAL WORKS
(5) HVAC WORKS
(6) FIRE ALARM WORKS
Inspection and test item for concrete and steel structure work for building shall refer to document no S- A000-1670-101 (ACCS-40
411-AS01-C-PLN-0011), SITE INSPECTION AND TEST PLAN FOR CIVIL WORKS & STEEL STRUCTURE.
6. ATTACHMENT
0-001 Attachment-1
UBCONTRACTOR can proceed with the test /

SUBCONTRACTOR shall submit inspection
R’s Inspector must be notified in advance and may be

n notification to CONTRACTOR.
s as applicable for review and approval.
n and / or testing include reporting.
gory required during construction stage of project
ategories:
er to document no S- A000-1670-101 (ACCS-40-

L WORKS & STEEL STRUCTURE.
AIR SEPARATION UNIT (ASU) INSPECTION AND TEST PLAN (ITP) FOR BUILDING COMPANY No. : ACCS-40-411-A
PROJECT INTERIOR & EXTERIOR FINISHING WORK CONTRACTOR No. : S-A000-167
Contract No :
Contractor : JGC Indonesia Location : Sumbawa, West Nusa Tenggara, Indonesia

Work Scope : Building
A : Approval R : Review S/C : SUBCONTRACTOR

W : Witness SW : Spot Witness P : Provide JGC : JGC Indonesia
H : Hold Point M : Monitor AMIN : PT. Amman Mineral Industry
V : Verification
Inspection Level
No Activity Description Reference Document Acceptance Criteria Verify Doc.
S/C JGC
1 Material Receiving
1.1 Visual
- Packaging ITR-GEN-001 M W
- Storage ITR-GEN-001 M W
Approved Specification, Approved Drawing & As per Material Approval Request, Approved Procedure /
Procedure Manufacturer Recommendation
1.2 Type & size, free from damages ITR-GEN-001 M W
1.3 Documents review (certificates, etc.) ITR-GEN-001 M R
2 Ceiling Works
2.1 Material : accepted and conformed to specification prior installation Material Approval Request, Approved Drawing &
Procedure
ITR-4000-001 M W
2.2 To check M&E items installation above ceiling has been completed Completed signed of hand over M&E installation above
ceiling
ITR-4000-001 M W
2.3 Type, elevation of edge moldings & ceiling hanger Material Approval Request & Approved Drawing ITR-4000-001 M W
2.4 Verify location and size of ceiling mount M&E equipment / fixtures Approved Drawing ITR-4000-001 M W
Approved Specification, Approved Drawing &

2.5 Location, alignment, elevation and rigidity of ceiling suspension system Procedure - Alignment ITR-4000-001 M W
- Elevation
- Rigidity
2.6 Ceiling Panel & Insulation board / blanket installation Material Approval Request & Approved Drawing ITR-4000-001 M W
2.7 Surface condition for exposed ceiling frame and panel boards Material Approval Request ITR-4000-001 M W
3 Wall / Partition Work
3.1 Masonry : Hollow Concrete Block
3.1.1 Material : accepted and conformed to specification prior installation Material Approval Request, Approved Drawing &
Procedure
ITR-4000-002 M W
3.1.2
Setting-out, marking center and both side of block Approved Drawing ITR-4000-002 M W
3.1.3 Dowels and anchors location, incl. mortar fill around dowel and use of chemical for anchor Approved Drawing & Procedure ITR-4000-002 M W
3.1.4 Mixing of grout / mortar using approved proportion and gauge boxes Mix proportion 1 : 5 (cement : sand) common wall ITR-4000-002 M W
Mix proportion 1 : 3 (cement : sand) for trassam wall
3.1.5 Alignment and plumbness of walls - Alignment ITR-4000-002 M W
- Plumbness

3.1.6 Arrangement of stiffener columns and bond beams
Procedure
Approved Drawing ITR-4000-002 M W
3.1.7 Size and location of joints, control and expansion joints Approved Drawing ITR-4000-002 M W
3.1.8 Ties and vertical - horisontal reinforcement bar / mesh arrangement Approved Drawing ITR-4000-002 M W
3.1.9 Location of electrical conduit, box and sleeve pipe, etc. Approved Drawing & Procedure ITR-4000-002 M W
3.1.10 Location and size of openings and penetrations Approved Drawing ITR-4000-002 M W
3.1.11 Grouting / Mortar test Procedure Subcont form report M W
Cleaning Procedure ITR-4000-002 M W

3-Jan-2012
3-Jan-2013 Curing at least carried out of 7 days, 2 times each day ITR-4000-002 M W
3.2 Plastering
3.2.1 Material : accepted and conformed to specification prior installation Approved Drawing & Procedure ITR-4000-003 M W
3.2.2 Protections for permanent finishes and fittings Procedure ITR-4000-003 M W
3.2.3 Check concealed M & E items has been installed (all embeded Material) Completed signed of hand over M&E installation inside
wall plastered
ITR-4000-003 M W
3.2.4 Condition of application surfaces (i.e: Roughness / scratching prior to plastering) Procedure ITR-4000-003 M W
3.2.5 Corner and joint beads setting Plumbness tolerance ±2 mm/M ITR-4000-003 M W
3.2.6 Location and size of openings and penetrations Approved Drawing ITR-4000-003 M W
3.2.7 Mixing of mortar using approved proportion and gauge boxes Mix proportion 1 : 4 (cement : sand) ITR-4000-003 M W
3.2.8 Application of bonding agent and base coat Manufacturer standard ITR-4000-003 M W
3.2.9 Thickness reference for vertical & horisontal direction of plastering - Vertical reference minimum @1000 mm maximum 1200
mm, start 300 mm from corner side
ITR-4000-003 M W
- Horisontal 300 mm bottom from ceiling elevation and

300 mm above floor finish
3.2.10 Thickness, Straightness, Flatness and Appearance - Thickness ITR-4000-003 M W
- Straightness & flatness : 80 gr thick of paper not pass

when jidar aluminium pinned to the plastered surface
3.2.11 Cleaning around permanent finishes and fittings Procedure ITR-4000-003 M W
3-Feb-2012 Mortar test Procedure Subcont form Report M W
Curing at least carried out of 7 days, 2 times each day ITR-4000-003 M W

3-Feb-2013
Procedure
V : Verification
Inspection Level
S/C JGC
3.3 Tile Work (Wall)
3.3.1 Material : accepted and conformed to specification prior installation Material Approval Request & Approved Drawing ITR-4000-004 M W
3.3.2 Layout, marking, starting point position, elevation reference and check of substrate Approved Drawing ITR-4000-004 M W
3.3.3 Check location and size of concealed M&E items (if any) Completed signed of hand over M&E installation inside ITR-4000-004 M W
To check waterproofing requirement for wet wall area and make sure the work has been
3.3.4
completed
Completed signed of leakage test document ITR-4000-004 M W
3.3.5 Verify type, pattern and layout of tiles Material Approval Request & Approved Drawing ITR-4000-004 M W
3.3.6 Corner, plinth and joint beads setting Procedure ITR-4000-004 M W

Procedure
3.3.7 Method, type, mixing ratio and application of bedding mortar / grout or adhesive Mix bedding mortar 1 : 3 (cement : sand) ITR-4000-004 M W
3.3.8 Alignment, level and flatness / evenness of installed tiles - Flatness ITR-4000-004 M W
3.3.9 Conditions of cut tile edges and projection round embedded pipes and fitting Procedure ITR-4000-004 M W
3.3.10 Check adhesion of tiles by sounding (void) & surface appearance Procedure ITR-4000-004 M W
3.3.11 Type, color and application of grout for tile joints Material Approval Request ITR-4000-004 M W
3.3.12 Cleaning and polishing Procedure ITR-4000-004 M W
3.4 Gypsum Board Partition
3.4.2 Layout, elevation and marking Approved Drawing ITR-4000-005 M W
3.4.3 Location and size of wall openings Approved Drawing ITR-4000-005 M W
3.4.4 Alignment, spacing and rigidity of runners / studs - Alignment ITR-4000-005 M W
- Rigidity
3.4.5 Reinforcement for wall openings, wall mounted M&E items, equipment, fixtures and fittings etc. Procedure ITR-4000-005 M W
3.4.6 Check concealed M&E items has been completed Completed signed of hand over M&E installation inside
partition
ITR-4000-005 M W
3.4.7 Insulation board / blanket installation Procedure ITR-4000-005 M W
3.4.8 Type and thickness of wall board Material Approval Request & Approved Drawing ITR-4000-005 M W
3.4.9 Wall board layout, height, number and spacing of tapping screws Material Approval Request & Approved Drawing ITR-4000-005 M W
3.4.10 Treatment of cut board edges, board joints and corner beads Manfacturer standard ITR-4000-005 M W
3.4.11 Straightness, verticality and flatness ± 2mm / 1.2 M flatness verticality tolerance ITR-4000-005 M W
3.4.12 Seal for penetrations of fire rated wall

Procedure ITR-4000-005 M W
Procedure
4 Floor Work
4.1 Tile Work (Floor)
4.1.2 Layout, marking, starting point position and check of substrate / underlayer Approved Drawing ITR-4000-006 M W
4.1.3 Check location and size of concealed M&E items Completed signed of hand over M&E installation under
tile floor
ITR-4000-006 M W
4.1.4To check waterproofing requirement (if any), make sure the work has been completed and no
leakage found
Completed signed of leakage test document ITR-4000-006 M W
4.1.5 Verify type, pattern and layout of tiles Material Approval Request & Approved Drawing ITR-4000-006 M W
4.1.6 Corner and joint beads setting Procedure ITR-4000-006 M W

Procedure
4.1.7 Method, type, mixing ratio and application of bedding mortar / grout or Adhesive Mix bedding mortar 1 : 3 (cement : sand) ITR-4000-006 M W
4.1.8 Alignment, level and flatness / evenness of installed tiles ± 3mm / 1.2 M for flatness tolerance ITR-4000-006 M W
4.1.9 Conditions of cut tile edges and projection around embedded pipes and fitting Procedure ITR-4000-006 M W
4.1.10 Check adhesion of tiles by sounding Procedure ITR-4000-006 M W
4.1.11 Type, color and application of grout for tile joints Material Approval Request \ ITR-4000-006 M W
4.1.12 Cleaning and polishing Procedure ITR-4000-006 M W
COMPANY No. : ACCS-40-411-AS01-S-PLN-0201
CONTRACTOR No. : S-A000-1670-201
Contract No :
Revision: 2A
Inspection Level
REMARKS
JGC AMIN
W R
W R
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R R
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Inspection Level
REMARKS
JGC AMIN
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Contract No :


V : Verification
Inspection Level
S/C JGC
4.2 Raise Floor
4.2.2 Conditions of sub floor Procedure ITR-4000-007 M W
4.2.3 Marking and verification of panel layout Approved Drawing & Procedure ITR-4000-007 M W
4.2.4 Location and elevation of steel support for instrument / electrical panel Approved Drawing ITR-4000-007 M W
4.2.5 Alignment, elevation and rigidity of pedestals installed per manufacturer's recommendation. Procedure ITR-4000-007 M W
4.2.6 Location and number of floor openings / penetrations Approved Drawing ITR-4000-007 M W
Procedure
4.2.7 Level and flatness check of floor ± 3 mm / 1.2 M for flatness tolerance ITR-4000-007 M W
4.2.8 Treatment of cut panel edges Procedure ITR-4000-007 M W
4.2.9 Expansion gap at all abutments with seal Procedure ITR-4000-007 M W
4.2.10 Seal for penetrations of floor panels Procedure ITR-4000-007 M W
4.2.11 Electrical continuity and earth bonding Approved Drawing ITR-4000-007 M W
4-Feb-2012 Cleaning Procedure ITR-4000-007 M W
5 Doors & Windows
5.1 Material : accepted and conformed to specification prior installation Material Approval Request & Approved Drawing ITR-4000-008 M W
5.2 Setting-out Approved Drawing ITR-4000-008 M W
5.3 Location and size of structural opening Approved Drawing ITR-4000-008 M W
5.4 Type, size, location and orientation of door / window being installed Material Approval Request & Approved Drawing ITR-4000-008 M W
5.5 Conditions of anchors / fasteners Procedure ITR-4000-008 M W
5.6 Grouting for threshold Procedure ITR-4000-008 M W
5.7 Alignment, plumb, elevation and orientation ± 2 mm / 1.2 M for plumbness tolerance ITR-4000-008 M W
5.8 Rigidity of frame fit-up / fixing with structure Procedure ITR-4000-008 M W
5.9 Grouting for gap between frame and structure Procedure ITR-4000-008 M W
5.10 Paint finish Material Approval Request & Manufacturer Standard ITR-4000-008 M W
5.11 Type of glass and face direction for installation Approved Drawing ITR-4000-008 M W
5.12 Bead / Seal conditions for glass panels Approved Drawing ITR-4000-008 M W
5.13 Type, location and orientation of Hardware fitting (hinge, lock case, keys, handle, panic bar) Material Approval Request & Approved Drawing ITR-4000-008 M W
5.14 Accessories : Door stoper, door closer, Earth bonding Material Approval Request & Approved Drawing ITR-4000-008 M W
5.15 Labels for fire rated doors / windows Procedure ITR-4000-008 M W
5.16 Functional / operational check

Procedure ITR-4000-008 M W
Procedure
6 Coating Waterproofing
6.1 Material : accepted and conformed to specification prior installation Material Approval Request & Approved Drawing ITR-4000-009 M W
6.2 Location of upstand, drain, etc. Approved Drawing ITR-4000-009 M W
6.3 Surface conditions (dry, clean, smooth, undamaged, etc.) Procedure ITR-4000-009 M W
Procedure
6.4 Application of primary waterproofing Material Approval Request & Manufacturer Standard ITR-4000-009 M W
6.5 Installation of coating waterproofing at corners, risers, end stop, penetrations and drain Procedure & manufacturer standard ITR-4000-009 M W
6.6 Water leak test / ponding test Procedure ITR-4000-014 M W
7 Painting for Building
7.1 Material : accepted and conformed to specification prior application Material Approval Request & Approved Drawing ITR-4000-010 M W
7.2 Mock up Procedure ITR-4000-010 M W
7.3 Check Surface condition, moisture content, flatness, wall filler already applied Moisture content shall be less 20 % ITR-4000-010 M W
7.4 Ensure the correct tools is implemented as manufacturer recommendation Approved Specification, Approved Drawing & Material Approval Request & Procedure ITR-4000-010 M W
Procedure
Procedure
7.5 Ensure the application condition (Weather, Relative Humidity) as per
manufacturing standard & specification
Material Approval Request & Procedure ITR-4000-010 M W
7.6 Coat thickness each layer (wet thickness) Manufacturer standard ITR-4000-010 M W
7.7 To check the straightness of painting line when meet floor skirting, ceiling & corner line Procedure ITR-4000-010 M W
Contract No :
Revision: 2A
Inspection Level
REMARKS
JGC AMIN
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W SW
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Contract No :


V : Verification
Inspection Level
S/C JGC
8 Stair & Handrail
8.1 Material : accepted and conformed to specification prior installation Approved Drawing & Specification ITR-4000-011 M W
8.2 Verify location as specified in drawing Approved Drawing ITR-4000-011 M W
8.3 Verify material are clean, undamaged & properly stored Procedure ITR-4000-011 M W
8.4 Verify stair & handrail installation : support, fixings as per drawing spec. Approved Specification, Approved Drawing & Approved Drawing ITR-4000-011 M W
Procedure
8.5 Check dimension (height, width) as per specification and drawing Approved Drawing ITR-4000-011 M W
8.6 Check handrail column is installed firmly Procedure ITR-4000-011 M W
8.7 Straightness & Alignment handrail Procedure ITR-4000-011 M W
9 Fence, Louvers, Grill and Bird Screen (if Any)
9.2 Verify Location as specified in drawing Approved Drawing ITR-4000-012 M W
9.3 Verify material are clean, undamaged & properly stored Procedure ITR-4000-012 M W
9.4 Verify partition installation : support, fixings as per drawing spec. Approved Specification, Approved Drawing & Approved Drawing ITR-4000-012 M W
Procedure
9.5 Check fence column is installed firmly Procedure ITR-4000-012 M W
9.6 Check door installed firmly and accessories installed as per drawings - specification. Approved Drawing ITR-4000-012 M W
9.7 Plumbnesss and allignment the fence Procedure ITR-4000-012 M W
10 Floor Hardener Topping
10.2 Protection for permanent finishes and fittings Procedure ITR-4000-013 M W
10.3 Condition of concrete base surfaces, shall be roughened Procedure & manufacturer standard ITR-4000-013 M W
10.4 Alignment, level and flatness Procedure ITR-4000-013 M W
10.5 Points and control joint board / beads setting (if any) Approved Drawing ITR-4000-013 M W
10.6 Application of bonding agent Procedure & manufacturer standard ITR-4000-013 M W

Procedure
10.7 Mixing of granolithic cement concrete topping using approved proportion and gauge boxes Manufacturer standard ITR-4000-013 M W
10.8 Laid floor hardener 2 to 3 hours after topping concrete laid Procedure ITR-4000-013 M W
10.9 Granolithic cement concrete test Procedure ITR-4000-013 M W
10.10 Finishing, level and flatness ± 3 mm / 1.2 M for flatness tolerance ITR-4000-013 M W
10.11 Cleaning & curing Procedure ITR-4000-013 M W
10.12 Seal for expansion / control joints (if any) Procedure ITR-4000-013 M W

ITR-4000-015 &
10 Final Visual Inspection of Building Works Approved Drawing & Procedure M W
Procedure Punchlist
Contract No :
Revision: 2A
Inspection Level
REMARKS
JGC AMIN
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ITR LIST
No Description
1 Material Receiving
2 Ceiling Works
3.2 Plastering
4 Floor Work
4.1 Tile Work (Floor)
4.2 Raise Floor
5 Doors & Windows
6 Coating Waterproofing
8 Stair & Handrail
9 Fence, Louvers, Grill and Bird Screen (if Any)
10 Floor Hardener Topping
11 Final Visual Inspection of Building Works
12 Grouting / Mortar test
13 Waterproofing Leak test
T
ITR
ITR-GEN-001
ITR-4000-001
ITR-4000-002
ITR-4000-003
ITR-4000-004
ITR-4000-005
ITR-4000-006
ITR-4000-007
ITR-4000-008
ITR-4000-009
ITR-4000-010
ITR-4000-011
ITR-4000-012
ITR-4000-013
ITR-4000-015 & Punchlist
Subcont form Report
ITR-4000-014
ITR-GEN-001
Doc.No.:
AIR SEPARATION UNIT (ASU) PROJECT
Contract No :
SUBJECT : MATERIAL INSPECTION REPORT Project No : Rev.2A
Project AIR SEPARATION UNIT (ASU) PROJECT
Client PT. AMMAN MINERAL INDUSTRY

Location
Reff. Dwg.
Material/Equipment identification
a. Material /Equipment Name :
b. Equipment Tag Number :
c. Purcahse Order Number :
d. Suplier/ Manufacture Name :
e. Material Approval Request (MAR No) :
f. Data Sheet No :
g. Batch no (if any) :
h. Packing List :
i. Inspection Release Certificate :
NO DESCRIPTION QTY CONFORMANCE TO SPECT. REMARKS

YES NO
Prepared By: Checked / Approved By: Reviewed / Witnessed by

SUBCONTRACTOR CONTRACTOR COMPANY
Print Name
Signature
Date
ITR-4000-001
AIR SEPARATION UNIT (ASU) Doc.No :
Contract No:
PROJECT
Subject : CEILING WORK Project No : Rev.2A
Project : AIR SEPARATION UNIT (ASU) PROJECT Date :
Client : PT. Amman Mineral Industri RFI No :
General
a. Area/Building Name
b. System / Sub-System
c. Part/Location
d. Reference Drawing/Specification
e. Type of Ceiling (Mark the inspected item) Suspended Weather Resistant
Gypsumboard WR Board
Gypsum Tyle WR Tile
Expose
No Activities ACC REJ N/A Remarks

1 Check Material :accepted and conformed to specification prior installation
2 Marking and verification of ceiling panel layout
3 Ensure that M&E items above ceiling has been completed
4 Type and elevation of edge moldings
5 Type, size and spacing of ceiling hangers
6 Verify the location and size of ceiling mount M&E equipment / fixtures
7 Location, alignment and rigidity of ceiling suspension system

8 Elevation & Flatness of ceiling suspension system
9 Insulation board / blanket installation
10 Type and thickness of ceiling panels / boards
11 Ceiling panels / boards installation
12 Treatment of cut panel / board edges and board joints
13 Surface condition for exposed ceiling frame and panel boards
Remarks :
Prepared by Checked/ Reviewed / Witnessed by

Approved by
SUBCONTRACTOR CONTRACT COMPANY
Print Name OR
Signature
Date
ITR-4000-002
Contract No:
PROJECT
Subject : Wall/Partition Work (Masonry : Concrete Block) Project No : Rev.2A
Project : AIR SEPARATION UNIT (ASU) PROJECT DATE :
Client : PT. AMMAN MINERAL INDUSTRI RFI.NO :
General
c. Part/ Location

1 Check Material : accepted and conformed to specification prior installation
2 Setting out, marking center & both side of block line
3 Dowels and anchors location
4 Pre-wetting of concrete block before use
5 Mixing of grout / mortar using approved proportion
6 Mortar speciment preparation as per specification
7 Alignment and plumbness of walls
8 Arrangement of stiffener columns and bond beams
9 Total Thickness Check as per specification
10 Size and location of joints, control and expansion joints
11 Ties and vertical - horisontal reinfrocement bar / mesh arrangement
12 Location and type of electrical conduit, box and sleeve pipe etc
13 Location and size of openings and penetrations
14 Grouting / Mortar test
15 Cleaning
16 Curing
Remarks :
Prepared by Checked/Approved by Reviewed / Witnessed by

Print Name
Signature
Date
ITR-4000-003
Doc.No :
AIR SEPARATION UNIT (ASU) Contract No:
PROJECT
Subject : Wall/Partition Work ( Plastering) Project No : Rev.2A
Client : PT. AMMAN MINERAL INDUSTRI RFI No :
General
a. Area/ Building Name
c. Part/Location

2 Protections for permanent finishes and fittings
3 Check concealed M & E items has been installed (all embeded Material)
4 Condition of application surfaces
5 Corner and joint beads setting
6 Location and size of openings and penetrations
7 Mixing of mortar using approved proportion
8 Application of bonding agent and base coat
9 Thickness, Straightness, Flatness and Appearance
10 Cleaning around permanent finishes and fittings
11 Mortar Test
12 Curing
Remarks :
Prepared by Checked/Approved by Reviewed / Witnessed

SUBCONTRACTOR CONTRACTOR by COMPANY
Print Name
Signature
Date
ITR-4000-004
PROJECT Contract No:
Subject : Wall/Partition Work (Tile Work for Wall) Project No : Rev.2A
General
c. Part/Location
2 Layout, marking and check of substrate

3 Check location and size of concealed M&E items
4 Verify the type, pattern and layout of tiles
5 Corner, plinth and joint beads setting
Method, type, mixing ratio and application of bedding mortar / grout or
6
adhesive
7 Alignment, level and flatness / evenness of installed tiles
8 Conditions of cut tile edges and projection round embedded pipes and fitting
9 Check adhesion of tiles by sounding (void) & surface appearance

10 Check gap of tiles prior to grout application
11 Type, color and application of grout for tile joints
12 Type, color and application of seal for control joints
13 Cleaning and polishing
Remarks :

Print Name
Signature
Date
ITR-4000-005
Contract No:
PROJECT
Subject : Wall/Partition Work (Gypsumboard Partition) Project No : Rev.2A
General
c. Part/Location

2 Layout and marking
3 Location and size of wall openings
4 Location, alignment, spacing and rigidity of runners / studs installed Per

manufacturer's recommendation
5 Reinforcement for wall openings, wall mounted M&E items, equipment,fixtures

and fittings etc
6 Check concealed M&E items has been completed
7 Insulation board / blanket installation
8 Type and thickness of wall board
9 Wall board layout, height, number and spacing of tapping screws
10 Treatment of cut board edges, board joints and corner beads
11 Straightness and flatness
12 Expansion / control joint
13 Seal for penetrations of fire rated wall
Remarks :

Print Name
Signature
Date
ITR-4000-006
Subject : Tiles Work (Floor) Project No : Rev.2A
General
c. Part/Location

4 Verify the type, size, pattern and layout of tiles
6 Method, type, mixing ratio and application of bedding mortar / grout or

Adhesive
8 Conditions of cut tile edges and projection around embedded pipes and fitting
9 Check adhesion of tiles by sounding

Remarks :

Print Name
Signature
Date
ITR-4000-006
Subject : Tiles Work (Floor) Project No : Rev.2A
General
c. Part/Location

4 Verify the type, size, pattern and layout of tiles
6 Method, type, mixing ratio and application of bedding mortar / grout or

Adhesive
8 Conditions of cut tile edges and projection around embedded pipes and fitting
9 Check adhesion of tiles by sounding

Remarks :

Print Name
Signature
Date
ITR-4000-007
Subject : Raised Floor Project No : Rev.2A
General
c. Part/Location

2 Conditions of sub floor
3 Marking and verification of panel layout
4 Location and elevation of steel support for instrument / electrical panel
5 Alignment, elevation and rigidity of pedestals installed per manufacturer's
recommendation.
6 Location and number of floor openings / penetrations
7 Level and flatness check of floor
8 Treatment of cut panel edges
9 Expansion gap at all abutments with seal
10 Seal for penetrations of floor panels
11 Anti static
12 Cleaning
Remarks :

Print Name
Signature
Date
ITR-4000-008
Doc.No :
PROJECT
Subject : Doors & windows Project No : Rev.2A
General
c. Part/Location

2 Setting out
3 Location and size of structural opening
4 Type, size, location and orientation of door / window being installed
5 Conditions of anchors/fasteners for frame
6 Grouting for threshold
7 Alignment plumb elevation and orientation
8 Rigidity of frame fit-up / fixing with structure
9 Grouting for gap between frame and structure
10 Paint finish
11 Type of glass and face direction for installation
12 Bead / Seal conditions for glass panels
13 Type, location and orientation of Hardware fitting
14 Earth bonding
15 Labels for fire rated doors / windows
16 Functional / operational check
Remarks :

Print Name
Signature
Date
ITR-4000-009
Doc.No :
PROJECT
Subject : Waterproofing Project No : Rev.2A
General
c. Part/Location

2
Location of up-stands, pipe penetration, fondation bases, raisers, drain etc
3 Cant installation / Corner fillet sand cement mortar
4 Surface conditions (dry, clean, smooth etc.)
5 Type & application of waterproofing
6 Waterproofing membrane direction, lap length, joint treatment etc
7 Installation of waterproofing membrane at corners, risers, end stop,
penetrations and drain
8 Water leak test:
9 Installation of insulation board, vapor barrier, fabric etc
10 Seal for joints and gaps
11 Protection gravel
12 Protection concrete / mortar
Remarks :
Prepared by Checked/Approved by Reviewed / Witnessed

SUBCONTRACTOR CONTRACTOR by COMPANY
Print Name
Signature
Date
ITR-4000-010
Doc.No :
PROJECT
Subject : Painting Project No : Rev.2A
General
c. Part/Location

2 Mock up
3 Check Surface condition, moisture content, flatness, wall filler already applied
4 Ensure the correct tools is implemented as manufacturer recommendation
5 Ensure the application condition (Weather, Relative Humidity) as per

manufacturng standard & specification
6 Coat thickness each layer (wet thickness)
Remarks :

Print Name
Signature
Date
ITR-4000-011
Doc.No :
PROJECT
Subject : Stair & Handrail Project No : Rev.2A
General
c. Part/Location

1 Material : accepted and conformed to specification prior installation
2 Verify location as specified in drawing
3 Verify material are clean, undamage & properly stored
4 Verify stair & handrail installation : support, fixings as per drawing and
specification
5 Check dimension (height, widht) as per specification and drawing
6 Check handrail column is installed firmly
7 Straightness & Alignment handrail
Remarks :
Prepared by Checked/Approved Reviewed / Witnessed by

SUBCONTRACTOR byCONTRACTOR COMPANY
Print Name
Signature
Date
ITR-4000-012
Doc.No :
PROJECT
Subject : Fence & Bird Screen Project No : Rev.2A
General
c. Part/Location

1 Material : accepted and conformed to specification prior installation
2 Verify Location as specified in drawing
3 Verify material are clean, undamage & properly stored
4 Verify partition installation : support, fixings as per drawing spec.
5 Check fence column is installed firmly
6 Check door installed firmly and accesories installed as per drawings -

specification.
7 Plumb the fence and door
Remarks :
Prepared by Checked/ Approved by Reviewed / Witnessed by

Print Name
Signature
Date
ITR-4000-013
Doc.No :
PROJECT
Subject : Floor Hardener Topping Project No : Rev.2A
General
c. Part/Location

2 Check concealed M & E items has been completed

3 Protections for permanent finishes and fittings
4 Condition of application surfaces
5 Points and control joint board / beads setting
6 Application of bonding agent and base coat
7 Wire mesh / re-bar installation
8 Mixing of mortar using approved proportion
9 Prepation of speciment
10 Mortar Test at a delivery (Slump)
11 Finishing, level and flatness
12 Cleaning around permanent finishes and fitting
13 Curing
14 Seal for expansion / control joints
Remarks :
Prepared by Checked/ Reviewed / Witnessed by

SUBCONTRACTOR Approved by
CONTRACT COMPANY
Print Name OR
Signature
Date
ITR-4000-014
Doc.No :
PROJECT
Project No : Rev.2A
Subject : LEAKAGE WATER TEST FOR ROOFING
General
c. Part/Location
Start Finish Result Note

Grid Line /
No Reference Drawing No Filling Media
Room Height Height
Time Time ACC REJ
(cm) (cm)
1
Remarks :
Prepared by Checked/Approved by Reviewed/Witnessed by

Print Name
Signature
Date
ITR-4000-015
Doc.No : Contract No:
AIR SEPARATION UNIT (ASU)
PROJECT
Subject : Final Inspection Project No : Rev.2A
Date :
Project : AIR SEPARATION UNIT (ASU) PROJECT
General
c. Part/Location
STATUS
No Activities ITR No Not Remarks
Complete N/A
Complete
1 Ceiling Works
2.2 Plastering
3 Floor Work
3.1 Tiles Work (Floor)
3.2 Raise Floor
5 Doors & Windows
6 Waterproofing
7 Mortar screed
9 Furniture
10 Stair & Handrail
11 Ladder
12 Fence and Bird Screen (if Any)
13 Wallpaper (if Any)
14 Metal Light Partition(if Any)
15 Grating
16 GRC Light Ornament
Prepared by Checked/ Reviewed /

SUBCONTRACTOR Approved by
CONTRACTOR Witnessed
COMPANYby
Print Name
Signature
Date
SUBJECT : PUNCH LIST REPORT
Project Title : AIR SEPARATION UNIT (ASU) PROJECT
Client : PT. Amman Mineral Industry
Area / Location Ref. Drawing No : Punch List No

: Unit / Facility
Item Punch List Category

No. Punch List Description A/B/C/D Approved
JGC AMIN
Note Category Description : : Signifies that the Punch list item, defect, or omission must be repaired or completed before issuance of SYSTEM CONSTRUCTION COMP
ABCD : Signifies that the Punch list item, defect,or omission may be completed after Construction Completion during Pre-Commissioning. All Categ
HANDOVER CERTIFICATE.
: Signifies that the Punch list item, defect, or omission can be repaired and/or completed after System HANDOVER, but must be done before
CONTRACTOR and COMPANY.
: Recognized as an item that is desirable to Operations, but is outside the project work scope agreement, is not operationally critical to the fa
Category "D" items will not prevent HANDOVER, TURNOVER, or ACCEPTANCE.
SUBCONTRACTOR CONTRACTOR
Prepared As Punch List Completed
Print Name
Signature
Date
Report No
Doc. No :
Contract No:
Project No: Rev.2A
System / Sub- :
System
Area :
Reference Dwg :
:
:
Target Date Accepted

Date Cleared S/C JGC AMIN Remarks
YSTEM CONSTRUCTION COMPLETION CERTIFICATE.

ing Pre-Commissioning. All Category "B" items must be corrected before issuance of a System
DOVER, but must be done before TURNOVER. Deviations must be agreed to in writing between
s not operationally critical to the facility, process, or people, and willbe rectified at COMPANY expense.
ACTOR COMPANY
Completed As Punch List Completed
Inspection and Test Plan for Building
Plumbing Work
Contractor : JGC Indonesia Location : Sumbawa, West Nusa Tenggara,
A W : Approval R : Review S/C : Sub-Contractor/Vendor

H V : Witness SW : Spot Witness P : Provide JGC : JGC Indonesia
: Hold Point M : Monitor/Surveillance AMIN : PT. Amman Mineral Industry
: Verification
Activity No. Activity Description Reference Document Acceptance Criteria
PREPARATION
A
Field Material Inspection

1
Material Approval Request (MAR),

1.1 Receiving Approved Design Drawing and Specification Approved Design Drawing and
Specification
ON GOING CONSTRUCTION
B
Installation
2
2.1 Cold Water Pipe Installation
Black Water Pipe Installation

2,2 As per Approved Procedures, Approved
Approved Procedures, Approved Design Drawing
Design Drawing
Grey Water Pipe Installation
2.3
Vent Pipe Installation

2.4
Plumbing & Sanitary Fixtures Installation Approved Procedures, Approved Design Drawing As per Approved Procedures, Approved
2.5 Design Drawing
Bio STP Installation

2.6
Rainwater Drainage Installation

2.7
TEST
C
Leakage Test (Black & Grey Water Piping)

3
As per Approved Procedures, Approved

4 Pressure Test (Cold Water Piping) Approved Procedures, Approved Design Drawing
Design Drawing
Water Flow Test

5

: Verification
Activity No. Activity Description Reference Document Acceptance Criteria
D FINAL INSPECTION/ RE-INSTATEMENT Approved Design Drawing Approved Design Drawing

Plan for Building COMPANY No.

Contract No
Rev.2A
Inspection Level
Verify Doc. REMARKS
S/C JGC AMIN
ITR-GEN-001 M W, R R
ITR-4000-601 M W, R SW
ITR-4000-602 M W, R SW
ITR-4000-603 M W, R SW
ITR-4000-604 M W, R SW
ITR-4000-605 M W, R SW
ITR-4000-606 M W, R SW
ITR-4000-607 M W, R SW
ITR-4000-608 M W, R SW
ITR-4000-609 M W, R SW
ITR-4000-610 M W, R SW
Inspection Level
Verify Doc. REMARKS
S/C JGC AMIN
ITR-4000-611 & Punchlist M W, R SW, R

AIR SEPARATION UNIT
(ASU) PROJECT
RFI. No :
Issue Date :
Rev No : Rev.2A
REQUEST FOR INSPECTION (RFI)
Attn : Mr……. Project Construction Manager
Gentlement,
We would like to have your presence for inspection according to the following schedules.
Civil Telecomunication Instrument Mech. Static
Piping Electrical Pipeline Mech. Rotating
Date and time Place / Area Inspection Item Remarks
Comments :
Prepared by Checked / Approved by Reviewed/Witnessed by

Print Name
Signature
Date
ITR LIST
No Activity Description
1 Material Receiving Inspection
2 Cold Water Pipe Installation
4 Black Water Pipe Installation
5 Grey Water Pipe Installation
6 Vent Pipe Installation
7 Plumbing & Sanitary Fixtures Installation
8 Bio STP Installation
10 Rainwater Drainage Installation
12 Leakage Test (Black & Grey Water Piping) for Plumbing Work
13 Pressure Test (Cold Water Piping) for Plumbing Work
14 Water Flow Test for Plumbing Work
15 FINAL INSPECTION
Verify Doc.
ITR-GEN-001
ITR-4000-601
ITR-4000-602
ITR-4000-603
ITR-4000-604
ITR-4000-605
ITR-4000-606
ITR-4000-607
ITR-4000-608
ITR-4000-609
ITR-4000-610
ITR-4000-611 &
Punchlist
SUBJECT : MATERIAL RECEIVING INSPECTION REPORT (MRIR)

Location :
Material/Equipment Identification
c. Purchase Order Number :
d. Suplier / Manufacture Name :
f. Datasheet No :
h. Packing List :
NO DESCRIPTION QTY CONFORMANCE TO SPEC

YES
Prepared By: Checked / Approved By:

Print Name
Signature
Date
ITR-GEN-001
Doc.No.:
Contract No :
Project No: Rev.2A

Reff.Dwg. :
Date :
NFORMANCE TO SPEC REMARKS

NO
Checked / Approved By: Reviewed / Witnessed by

CONTRACTOR COMPANY
33 / 103
ITR-4000-601
Doc.No :
PROJECT
Subject : COLD WATER PIPE INSTALLATION Project No : Rev.2A
General
c. Part/Location
No Activities ACC REJ N/A Remark

1 Verify Pipe Route is correct as per approved drawings
2 Verify Pipe Accessories have been completed ( Valve, Automatic Air Vent, etc.)
as per design drawing.
3 Verify Material of Pipe is correct as per approved specification
4 Verify Pipe Size is correct as per approved drawings
5 Verify Pipe Level is correct as per approved drawings
6 Verify Tightening Connection of Pipes
7 Verify Hangers and Pipe Supports
8 Verify Penetration Pipe On Wall / Roof / Floor
9 Verify piping identification is correct
Remarks :
Prepared by Checked/Approved by Reviewed/Witnessed

SUBCONTRACTOR CONTRACTOR by, COMPANY
Print Name
Signature
Date
ITR-4000-602
Doc.No :
PROJECT
Subject : BLACK WATER PIPE INSTALLATION Project No : Rev.2A
General
c. Part/Location

2 Verify Pipe Accessories have been completed ( Clean Out, Vent Cap etc.) as per
design drawing.
3 Verify Material of Pipe is correct as per approved speciffication
6 Verify Pipe Slope is correct
10 Verify Piping Identification is correct
Remarks :
Prepared by Checked/Approved by Reviewed/Witnessed by,

Print Name
Signature
Date
ITR-4000-603
Doc.No :
PROJECT
Subject : GREY WATER PIPE INSTALLATION Project No : Rev.2A
:
Client : PT. AMMAN MINERAL INDUSTRI RFI No
General
c. Part/Location

2 Verify Pipe Accessories have been completed ( Clean Out, Trap, Vent Cap
etc.) as per design drawing.
6 Verify proper venting on Black Water Piping Installation
7 Verify proper venting on Grey Water Piping Installation
10 Verify location of Clean Out is correct
Remarks :

Print Name
Signature
Date
ITR-4000-604
Doc.No :
PROJECT
Subject : VENT PIPE INSTALLATION Project No : Rev.2A
Date :
:
General
c. Part/Location
e. Equipment Tag Number
f. Manufacture Name
g. Model Number
h. Serial Number

2 Verify Pipe Accessories have been completed ( Vent Cap, etc.) as per design
drawing.
6 Verify proper venting on Black Water Piping Installation
7 Verify proper venting on Grey Water Piping Installation
10 Verify Vent Cap location is correct
Remarks :

Print Name
Signature
Date
ITR-4000-605
Doc.No :
PROJECT
Subject : PLUMBING & SANITARY FIXTURES INSTALLATION Project No : Rev.2A
General
c. Part/Location
f. Manufacture Name
g. Model Number
h. Serial Number

1 Verify Type of Plumbing Fixture is correct as per specification
2 Verify Location Pipe Sleeve of Plumbing Fixture as per drawing

Verify Location of Plumbing Fixture as per drawing, and clearance between
3 plumbing fixtures and from fixtures to adjacent wall are correct.
4 Verify alignment and level of Plumbing Fixture as per drawing

5 Penetration On Wall / Roof/ Floor have been caulked.
6 Verify cleanliness of plumbing fixture installation.
Remarks :
Prepared by Checked/Approved by Reviewed/Witnessed

by,
Print Name
Signature
Date
ITR-4000-606
Doc.No :
PROJECT
Subject : BIO STP INSTALLATION Project No : Rev.2A
Project Date :
: AIR SEPARATION UNIT (ASU) PROJECT
General
c. Part/Location
f. Manufacture Name
g. Model Number
h. Serial Number

1 Ensure Biotech Tank is not damage
Verify excavation was done according to dimensions specified for each type of
2 tank.
3 Ensure excavation bottom has been covered with a 15 cm-thick layer of sand,
and correctly leveled.
4 A 15 cm-thick layer of concrete has been poured over the sand bed and correctly
leveled.
5 Verify Aeration Pipe in Biotech Tank has been installed and support correctly
6 Verify slope and support of black water piping to inlet pipe of Biotech Tank is
correct.
7 Tank input and output pipes have been installed correctly.
8 A vent pipe has been installed correctly at top of tank.
Verify Biotech Tank has been filled completely with water before backfill their
9 surrounding area.
10 Ensure debris-free fine ballast shall be used as excavation backfill material.
11 Ensure tank integrity was not compromised during compaction.

12 Ensure excavation was back filled without compacting directly over tank or pipes.
13 Verify concrete slab was built over septic tank excavation area is correct.
14 Verify a concrete cover was installed over septic tank inspection lid is correct.
15 Verify Blower has been installed correctly.
16 Verify Sewage Water Lift Pump has been installed correctly.
Remarks :

Print Name
Signature
Date
ITR-4000-607
Doc.No :
PROJECT
Subject : RAINWATER DRAINAGE INSTALLATION Project No : Rev.2A
Date :
General
c. Part/Location
f. Manufacture Name
g. Model Number
h. Serial Number
No Activities ACC REJ N/A

1 Verify Pipe Route is correct
2 Verify Pipe Accessories have been completed ( Roof Drain etc.) as per design
drawing.
3 Verify Material of Pipe is correct
4 Verify Pipe Size is correct
5 Verify Pipe Level is correct
6 Verify Pipe Slope is correct
Remarks :

Print Name
Signature
Date
Rev.2A
Remarks
ITR-4000-608
Contract No:
PROJECT
Subject : LEAKAGE WATER TEST FOR PLUMBING WORK Project No : Rev.2A
Date :
:
General
c. Part/Location
f. Manufacture Name
g. Model Number
h. Serial Number
Start Finish Result

No Line No Reference Drawing No Filling Media
Height Height
Time Time ACC REJ
(cm) (cm)
1
Remarks :

Print Name
Signature
Date
Rev.2A
Note
ITR-4000-609
Doc.No :
PROJECT
Subject : PRESSURE TEST FOR PLUMBING WORK Project No : Rev.2A
Date :
General
c. Part/Location
f. Manufacture Name
g. Model Number
h. Serial Number
Spesific
a. Piping Class
b. P & ID No
c. Design Pressure
d. Test Pressure
e. Test Medium
f. Holding Time
g. Pressure Gauge No & Calibration
Validity
Start Finish Result

Filling
No Line No Reference Drawing No
Media
Press Time Press Time ACC REJ
Remarks :

Print Name
Signature
Date
Rev.2A
Note
ITR-4000-610
Doc.No :
Contract No:
Project No :
Subject : WATER FLOW TEST FOR PLUMBING WORK Rev.2A
Date :
General
c. Part/Location

f. Manufacture Name
g. Model Number
h. Serial Number
Plumbing Fixture No. Plumbing Fixture Water Flow Test of Plumbing RESULT
No Reference Drawing No. Name Fixture
ACC REJ N/A
Flow of Supply Water

Flow of Drainage Water
Remarks

Print Name
Signature
Date
Remarks
ITR-4000-611
Doc.No :
PROJECT
Subject : Final Inspection Project No : Rev.2A
Date :
General

c. Part/Location
We certify the scope of work definied in the above mentioned ITP is completed and is verified in accordance with attached list of ITR's. All acceptence
criteria described in the above mentioned ITP are met.
STATUS
No Activities ITR No Remarks
Complete Not Complete N/A
1 Cold Water Pipe Installation
2 Black Water Pipe Installation
3 Grey Water Pipe Installation
4 Vent Pipe Installation
5 Plumbing & Sanitary Fixtures Installation
6 Bio STP Installation
7 Panel STP Installation
8 Rainwater Drainage Installation
9 Leakage Test (Black & Grey Water Piping) For Plumbing
10 Work
Pressure Test (Cold & Hot Water Piping) For Plumbing Work
11 Water Flow Test For Plumbing Work
Remarks

Print Name
Signature
Date
Report No :
Doc. No :
Contract No:
SUBJECT : PUNCH LIST REPORT Project No:
Project Title : AIR SEPARATION UNIT (ASU) PROJECT System / Sub-

System
Client : PT. Amman Mineral Industry Area
Reference Dwg
Area / Location Ref. Drawing No : Punch List No Unit / :
: Facility :
Item Punch List Category Target Date

No. Punch List Description A/B/C/D Approved Date Cleared
JGC AMIN
Note Category Description : : Signifies that the Punch list item, defect, or omission must be repaired or completed before issuance of SYSTEM CONSTRUCTION COMPLETION CERTIFICATE.
ABC : Signifies that the Punch list item, defect,or omission may be completed after Construction Completion during Pre-Commissioning. All Category "B" items must be correc
D CERTIFICATE.
: Signifies that the Punch list item, defect, or omission can be repaired and/or completed after System HANDOVER, but must be done before TURNOVER. Deviations m
and COMPANY.
: Recognized as an item that is desirable to Operations, but is outside the project work scope agreement, is not operationally critical to the facility, process, or people, and
items will not prevent HANDOVER, TURNOVER, or ACCEPTANCE.
Print Name
Signature
Date
Report No :
Doc. No :
Contract No:
Project No: Rev.2A
System / Sub- :
System
Area :
Reference Dwg :
Date Accepted
Cleared S/C JGC AMIN Remarks
TION COMPLETION CERTIFICATE.

ng. All Category "B" items must be corrected before issuance of a System HANDOVER
e done before TURNOVER. Deviations must be agreed to in writing between CONTRACTOR
tical to the facility, process, or people, and will be rectified at COMPANY expense. Category "D"
COMPANY
As Punch List Completed
AIR SEPARATION UNIT (ASU) INSPECTION AND TEST PLAN (ITP) FIRE
PROJECT PROTECTION SYSTEM FOR BUILDING


: Verification
Activity No. Activity Description Reference Document
1 MATERIAL RECEIVING INSPECTION
Approved Specification, Packing List / Material

1.1 Material Receiving Inspection
Certificate
2
2.1
PORTABLE FIRE EXTINGUISHER
Final inspection of Portable Fire Extinguisher Installation Approved Drawing

ION AND TEST PLAN (ITP) FIRE COMPANY No.
TION SYSTEM FOR BUILDING CONTRACTOR No.
CONTRACT NO
West Nusa Tenggara, Indonesia Rev.2A
ndor
al Industry
Inspection Level
Acceptance Criteria Verify Doc. REMARKS
S/C JGC AMIN
ITR-GEN-001
As per Approved Specification, Packing List / Material
M W,R R
Certificate
As per Approved Drawing ITR-4000-401 M W,R SW, R

AIR SEPARATION UNIT
(ASU) PROJECT
RFI. No :
Issue Date :
Rev No :
Gentlement,
Comments :

Print Name
Signature
Date
ITR LIST
No ITR Description
1 MATERIAL RECEIVING INSPECTION REPORT

2 INSTALLATION CHECK PORTABLE FIRE EXTINGUISHER
ITR No
ITR-GEN-001
ITR-4000-401
SUBJECT : MATERIAL RECEIVING INSPECTION REPORT

Client PT. Amman Mineral Industry
Location Reff.Dwg.
f. Datasheet No :
h. Packing List :
NO DESCRIPTION QTY CONFORMANCE TO SPEC

YES
Prepared By:
SUBCONTRACTOR
Print Name
Signature
Date
SU) PROJECT ITR-GEN-001
Doc.No.:
Contract No :
Project No :

CONFORMANCE TO SPECT. REMARKS

YES NO

CONTRACTOR COMPANY
49 / 103
ITR-4000-401
PROJECT
Subject : INSTALLATION CHECK PORTABLE FIRE EXTINGUISHER Project No : Rev. 2A
Date :
General
c. Part/Location
f. Manufacture Name
g. Model Number
h. Serial Number
1 Check the Portable Fire Extinguisher according to approved specification
2 Check the Portable Fire Extinguisher is installed as per approved drawings
3 Check tag number of fire extinguisher as per approved drawings
4 Check the safety sign showing the location of fire extinguisher is installed above each
extinguisher
5 Check Portable Fire Extinguisher is clean and undamaged
6 Check easy access available for Portable Fire Extinguisher location
7 Check sign already installed
8 Ensure the pressure of portable fire extinguisher still in good condition and ready for used
9 Ensure the tagging already installed and correct
Remarks :
Prepared by Checked/Approved Reviewed/Witnessed

SUBCONTRACTOR byCONTRACTOR by, COMPANY
Print Name
Signature
Date
Rev. 2A
REMARKS
Area / Location Ref. Drawing No : Punch List No Unit /

: Facility
Item Punch List Description Punch List Category

No. A/B/C/D
Note Category Description : : Signifies that the Punch list item, defect, or omission must be repaired or completed before issuance of SYSTEM CONSTRUC
AB : Signifies that the Punch list item, defect,or omission may be completed after Construction Completion during Pre-Commission
CD CERTIFICATE.
: Signifies that the Punch list item, defect, or omission can be repaired and/or completed after System HANDOVER, but must b
: Recognized as an item that is desirable to Operations, but is outside the project work scope agreement, is not operationally c
Prepared As Punch List
Print Name
Signature
Date
Report No :
Doc. No :
PROJECT
Contract No:
Project No:
System / Sub- :
System
Area :
Reference Dwg :
Punch List No Unit / :
Facility :
Punch List Category Target Date Accepted Remarks

Approved Date Cleared S/C JGC AMIN
JGC AMIN
d before issuance of SYSTEM CONSTRUCTION COMPLETION CERTIFICATE.

ruction Completion during Pre-Commissioning. All Category "B" items must be corrected before issuance of a System HANDOVER
eted after System HANDOVER, but must be done before TURNOVER. Deviations must be agreed to in writing between
ork scope agreement, is not operationally critical to the facility, process, or people, and will be rectified at COMPANY expense.
CONTRACTOR COMPANY
s Punch List Completed As Punch List Completed
51 / 103
AIR SEPARATION UNIT (ASU) PROJECT Inspection and Test Plan COMPANY No.
Electrical Work for Buiding & Infrastructure CONTRACTOR No.
Contract No.
Contractor : JGC Indonesia Location : Sumbawa, West Nusa Tenggara

A W : Approval R : Review S/C : SUBCONTRACTOR

H V : Witness SW : Spot Witness P : Provide JGC : JGC INDONESIA
: Hold Point M : Monitor AMIN : PT. AMMAN MINERAL INDUSTRY
: Verification
Inspection Level
Activity No. Activity Description Reference Document Acceptance Criteria Verify Doc.
S/C
1 CABLE TRAY
1.1 PREPARATION
a). Material receiving inspection Data Sheet, Material certificate, DO,PO Material specification, Material ITR-GEN-001 M
certificate, DO,PO
1.2 INSTALLATION
Complied with approve drawings and

1 Inspection of cable tray support installation Installation details, Layout drawing Installation Detail ITR-4000-201 M
Complied with approve drawings and

2 Inspection of cable tray installation Installation details, Layout drawing Installation Detail ITR-4000-201 M
3 Completeness check of installation (fittings & accessories) Complied with approve drawings and
Installation details, Layout drawing Installation Detail ITR-4000-201 M
INSTALLATION FOR ELECTRICAL CABLES INSIDE BUILDING

2
2.1 PREPARATION
Material specification, Material

a). Material receiving inspection Data Sheet, Material certificate, DO,PO certificate, DO,PO ITR-GEN-001 M
Insulation Resistance /Continuity tests and Inspection of b). cables Cable drum schedule/cable schedule, Manufacturer ’s Complied with approve drawings and
before installation (on drum ), prior to release to instructions Installation Detail ITR-4000-204 M
site for installation
2.2 CABLE INSTALLATION INSIDE BUILDING
a). Cable glanding Approved Procedure & Design Drawing As Approved Procedure & Design ITR-4000-202 M
Drawing,
b). Cable Termination Approved Procedure & Design Drawing As Approved Procedure & Design ITR-4000-202 M
Drawing,
c). Cable Identification/markers Approved Procedure & Design Drawing As Approved Procedure & Design ITR-4000-202 M
Drawing,
2.3 TESTING
a). Insulation Resistance and Continuity test after glanding and termination As Approved Procedure & Design
Approved Procedure & Design Drawing Drawing, ITR-4000-202 M
COMPANY No.
CONTRACTOR No.
Contract No.
Rev. 2A
Inspection Level
REMARKS
JGC AMIN
W,R R
W,R SW , R
W,R SW , R
W,R SW , R
W,R R
W,R R
W,R SW , R
W,R SW , R
W,R SW , R
W,R SW, R
Contract No.
Contractor : JGC Indonesia Location : Sumbawa, West Nusa Tenggara

A W : Approval R : Review S/C : SUBCONTRACTOR

H V : Witness SW : Spot Witness P : Provide JGC : JGC INDONESIA
: Hold Point M : Monitor AMIN : PT. AMMAN MINERAL INDUSTRY
: Verification
Inspection Level
S/C
3 CONDUIT INSTALLATION
3.1 PREPARATION
a). Material receiving inspection Data Sheet, Material certificate, DO,PO Material specification, Material ITR-GEN-001 M
certificate, DO,PO
3.2 INSTALLATION
a). Conduit support installation check

Approved Procedure & Design Drawing As Approved Procedure & Design ITR-4000-205 M
Drawing,
b) Conduit & fitting installation check
Drawing,
c) Conduit system bonding check
Drawing,
d) Check for conduit wall penetration
Drawing,
e) Final Inspection Approved Procedure & Design Drawing As Approved Procedure & Design ITR-4000-205 M
Drawing,
4 POWER DISTRIBUTION SYSTEM
4.1 PREPARATION
Data Sheet, Material specification,

a). Material receiving inspection Data Sheet, Material certificate, DO,PO Material certificate, DO,PO ITR-GEN-001 M
4.2 INSTALLATION
Verify name plate details of small power devices, small a). power As Approved Procedure & Design
distribution boards, sockets outlets and welding Approved Procedure & Design Drawing Drawing, ITR-4000-205 M
outlets
As Approved Procedure & Design

b). Installation of Junction Boxes Approved Procedure & Design Drawing Drawing, ITR-4000-205 M
Installation of Lighting and small power distribution boards and power

c). As Approved Procedure & Design
devices Approved Procedure & Design Drawing Drawing, ITR-4000-205 M

d). Electrical earthing connections to the earthing system Approved Procedure & Design Drawing Drawing, ITR-4000-205 M

e). Check cable connection and tagging correct Approved Procedure & Design Drawing Drawing, ITR-4000-205 M

f). Final Inspection of Equipment Approved Procedure & Design Drawing Drawing, ITR-4000-205 M

g). Insulation Resistance Measurement Approved Procedure & Design Drawing Drawing, ITR-4000-205 M
4.3 TESTING (COMMISIONING)

a) Function Test Approved Procedure & Design Drawing Drawing, ITR-4000-207 M
COMPANY No.
CONTRACTOR No.
Contract No.
Rev. 2A
Inspection Level
REMARKS
JGC AMIN
W,R R
W,R SW , R
W,R SW , R
W,R SW , R
W,R SW , R
W,R SW
W,R R
W,R SW , R
W,R SW , R
W,R SW , R
W,R SW , R
W,R SW , R
W,R SW
W,R SW , R
W SW
Contract No.
Contractor :JGC Indonesia Location : Sumbawa, West Nusa Tenggara

AW : Approval
R : Review S/C : SUBCONTRACTOR
HV : Witness
SW : Spot Witness JGC : JGC INDONESIA
: Hold Point
P : Provide AMIN : PT. AMMAN MINERAL INDUSTRY
: Verification
M : Monitor
Inspection Level
S/C
5 LIGHTING AND RECEPTACLE INSTALLATION
5.1 PREPARATION

a. Material receiving inspection
Data Sheet, Material certificate, DO,PO Material certificate, DO,PO ITR-GEN-001 M
5.2 INSTALLATION (INSIDE BUILDING)
a). Check Lighting fixture installation, orientation and alignment Approved Procedure & Design Drawing As Approved Procedure & Design ITR-4000-211 M
Drawing,
b). Check installation of receptacle/socket outlet Approved Procedure & Design Drawing As Approved Procedure & Design ITR-4000-211 M
Drawing,
c). Check Instalation of Circuit Lighting as per Approved Drawing Approved Procedure & Design Drawing As Approved Procedure & Design ITR-4000-211 M
Drawing,
d). Final Check of Installation prior to Test of Lighting
Drawing,
5.3 TESTING (COMMISIONING)
a. Lighting & Receptacle circuit test Approved Procedure & Design Drawing As Approved Procedure & Design ITR-4000-212 M
Drawing,
b. Illumination quality check Approved Procedure & Design Drawing As Approved Procedure & Design ITR-4000-213 M
Drawing,
6 GROUNDING AND LIGHTNING PROTECTION SYSTEM
6.1 PREPARATION

a). Material receiving inspection Data Sheet, Material certificate, DO,PO Material certificate, DO,PO ITR-GEN-001 M
6.2 INSTALLATION
a). Underground grounding cable installation check Approved Procedure & Design Drawing As Approved Procedure & Design ITR-4000-214 M
Drawing,
b). Check Installation of Exothermic Weld Joints for Underground Cable Approved Procedure & Design Drawing As Approved Procedure & Design ITR-4000-214 M
Drawing,
c). Installation of grounding electrode Approved Procedure & Design Drawing As Approved Procedure & Design ITR-4000-214 M
Drawing,
d). Installation of grounding bar Approved Procedure & Design Drawing As Approved Procedure & Design ITR-4000-214 M
Drawing,
e). Aboveground grounding cable installation check Approved Procedure & Design Drawing As Approved Procedure & Design ITR-4000-214 M
Drawing,
f). Installation of lightning protection Approved Procedure & Design Drawing As Approved Procedure & Design ITR-4000-214 M
Drawing,
g). Grounding connection check Approved Procedure & Design Drawing As Approved Procedure & Design ITR-4000-214 M
Drawing,
h). Final Check Approved Procedure & Design Drawing As Approved Procedure & Design 'ITR-4000-214 / 'ITR-4000- M
Drawing, 215
6.3 TESTING
a). Earthing continuity test (Electrode-Earth Bar/Plant Earth Ring) Approved Procedure & Design Drawing As Approved Procedure & Design 'ITR-4000-214 / 'ITR-4000- M
Drawing, 215
b). Inspection resistance of each electrodes (Individual electrode) Approved Procedure & Design Drawing As Approved Procedure & Design 'ITR-4000-214 / 'ITR-4000- M
Drawing, 215
c). Inspection total resistance looping grounding
Approved Procedure & Design Drawing As Approved Procedure & Design 'ITR-4000-214 / 'ITR-4000- M
Drawing, 215
COMPANY No.
CONTRACTOR No.
Contract No.
Rev. 2A
Inspection Level
REMARKS
JGC AMIN
W,R R
W,R SW , R
W,R SW , R
W,R SW , R
W,R SW
W SW
W SW
W,R R
W,R SW , R
W,R SW , R
W,R SW , R
W,R SW , R
W,R SW , R
W,R SW , R
W,R SW , R
W,R SW
W,R SW, R
W,R SW, R
W,R SW, R
ITR LIST
No Activity Description
1 MATERIAL RECEIVING INSPECTION REPORT (MRIR)
2 INSPECTION INSTALLATION OF CABLE TRAY
3 INSPECTION OF ELECTRICAL CABLE INSTALLATION AND TERMINATION
4 INSPECTION & TEST RECORD OF JOINTING CABLE
5 INSULATION RESISTANCE AND CONTINUITY TEST RECORD ELECTRICAL CABLE DRUM BEFORE
INSTALLATION
6 INSPECTION INSTALLATION OF CONDUIT
7 INSPECTION INSTALLATION OF LIGHTING AND SMALL POWER DISTRIBUTION BOARD and TEST
RECORD
8 FUNCTION & PHASE SEQUENCE TEST RECORD
9 INSTALLATION OF SOCKET OUTLETS/WELDING OUTLETS
10 INSPECTION LIGHTING INSTALLATION OUTSIDE BUILDING
11 INSPECTION LIGHTING INSTALLATION INSIDE BUILDING
12 INSPECTION RECEPTACLE INSTALLATION
13 LIGHTING AND RECEPTACLE VOLTAGE CIRCUIT TEST RECORD
14 ILLUMINATION LEVEL MEASUREMENT TEST RECORD
15 INSPECTION OF SYSTEM EARTHING INSTALLATION and TEST RECORD
16 INSPECTION OF LIGHTNING PROTECTION SYSTEM INSTALLATION AND TEST RECORD

ITR NO
ITR-GEN-001
ITR-4000-201
ITR-4000-202
ITR-4000-203
ITR-4000-204
ITR-4000-205
ITR-4000-206
ITR-4000-207
ITR-4000-208
ITR-4000-209
ITR-4000-210
ITR-4000-211
ITR-4000-212
ITR-4000-213
ITR-4000-214
ITR-4000-215
AIR SEPARATION UNIT
(ASU) PROJECT
Doc. No :
Issue Date :
Gentlement,
Comments :
Prepared by Checked / Approved by

Print Name
Signature
Date
Manager
h. Static
. Rotating
Remarks
Reviewed/Witnessed by
COMPANY
SUBJECT : MATERIAL RECEIVING INSPECTION REPORT (MRIR)

Location :
f. Datasheet :
h. Packing List :
NO DESCRIPTION QTY CONFORMANCE TO SPE

YES
Prepared By:
SUBCONTRACTOR
Print Name
Signature
Date
SU) PROJECT ITR-GEN-001
Doc.No.:
Contract No :
Project No:
Reff Dwg Date :
:
CONFORMANCE TO SPECT. REMARKS

YES NO

CONTRACTOR COMPANY
57 / 103
AIR SEPARATION UNIT ITR-4000-201
(ASU) PROJECT
Contract No :
INSPECTION INSTALLATION OF CABLE TRAY

Project No. Client : PT. Amman Mineral Industry Date Page Doc. No. : 1 of
Main Contractor : PT. JGC Indonesia :
Sub-Contractor : :
:
Tag/ID No. System : Area/Location Sub-System No. :

No. System Desc. : Sub-System Desc. :
Layout Dwg No. : Rev. :
: :
No. Checks Description Result REMARKS

YES NO N/A
1 Check for material in accordance to Project Specification, verify quality and
condition.
2 Check supports are in accordance with design drawings.
3 Check size, routing, spacing and elevation are in accordance with
design drawings.
4 Verify correct type/size nut/bolt/washer are provided on each joints.
5 Ensure no sharp edges and confirm all rough edges removed.

6 Check insulation barriers provided between cable tray/rack and steel
supports, where applicable.
7 Check bending radius is satisfactory, installation of bends, change of
direction and supports.
8 Confirm all fasteners are tightened properly.
9 Verify adequate supports provided for cable tray system as per

actual site conditions.
10 Check cable tray system complies with typical installation details.
11 Verify installation of expansion joints at specified intervals and

supported.
12 Check repair of damaged galvanized coating after site fabrication
have been made good.
13 Correct type of nut/bolt/washer used and properly tightened (if applicable)
Remarks:
Prepared by, Checked / Approved by, Reviewed / Witnessed by,

Name
Signature
Date
1
REMARKS
ewed / Witnessed by,

COMPANY
AIR SEPARATION UNIT (ASU) ITR-4000-202
PROJECT
Contract No. :
INSPECTION OF ELECTRICAL CABLE INSTALLATION AND TERMINATION

Project No. :
Date :
Client : PT. Amman Mineral Industry Page : 1 of 1
Main Contractor : JGC Indonesia Doc. No. :
Sub-Contractor : Rev. :
Cable Tag No. : System No. : System Desc. :
System No. : Cable Type : Rated Voltage : N
: Test Voltage : VDC
Manufacturer : Ambient Temperature : °C Area/Location :
: Cable Schedule No. : Rev. :
NO CHECK DESCRIPTION RESULT

YES NO N/A
1 Verify type/size of cable gland
2 Verify that correct IP washer is fitted
3 All gland components are correctly assembled and tightened
4 Ensure that armour is not visible
5 Shroud provided wherever applicable
6 Correct earth bonding provided, if applicable
7 Correct wire/terminal lugs used
8 Verify terminations at both ends are as per phase colour code/core numbering and
identification
9 No physical damage or kinks on conductor inside the enclosure
10 Conductor is not touching with the cable entry component
11 Properly dressed inside the enclosure
12 Verify wire twisting is maintained close to termination point
13 Correct cable marker and core marker provided
14 No loose crimping or connections
15 Wires are terminated at correct terminals
16 Verify cables are reconnected & tightened after testing (torque if required shall be executed)
Continuity IR of Power Cable (MΩ)

Three Phase Single Phase
L1 - All other L2 - All other L3 - All other N - All other P - All N - All
cores/E cores/E cores/E cores/E Shield - E other other
cores/E cores/E
Test Equipment Type Manufacture Model No. Serial No.
Remarks :
Prepared by, Checked / Approved by, Reviewed / W
SUBCONTRACTOR CONTRACTOR COMP
Name
Signature
Date
MINATION
: 1 of 1
:
:
Sub-
:
: No. of Cores & Size
: Weather
SULT REMARKS
N/A
IR of Control Cable (MΩ)
Core-Core Core - E
Cal Due Date

Reviewed / Witnessed by,
COMPANY
PROJECT
Contract N o :
.
INSPECTION & TEST RECORD OF JOINTING CABLE

Project No. Client : Date Page
Main Contractor Sub- : PT. Amman Mineral Industry Doc. No.
Contractor : JGC Indonesia Rev.
:
Area/Location: Tag No.: System No:
Drawing No. : Rev. :
Cable Manufacturer: No.of Cores & Size: Voltage Rating:
From: To:
Details of Cable Joint/Termination kit
Manufacturer: Type: Part No:
Title of Installation Instruction Manual:
Installation Instruction Manual No: Voltage Rating:
Details of Technician
Name: Company:
Certificate No: Certificate Issued by:
Cert. Issued on: Certificate Valid up to:
Insulation Resistance and Continuity Test Results (Test Voltage: V DC )

Before Splice Joint After Splice Joint
A-Supply Side(M Ω) Continuity B-Load Side (MΩ) Continuity Side A&B (MΩ) Contin
L1-L2: L1 : L1-L2: L1 : L1-L2: L1 :
L2-L3: L2 : L2-L3: L2 : L2-L3: L2 :
L1-L3: L3 : L1-L3: L3 : L1-L3: L3 :
L1/L2/L3 to Shield : L1/L2/L3 to Shield : L1/L2/L3 to Shield :
Armour/Earth: Armour/Earth: Armour/Earth:
Shield to Shield to Shield to

Armour/Earth: Armour/Earth: Armour/Earth:
Visual Inspection Result

YES NO
1. Verify kit components against packing list and ensure that joint kit is suitable for the cable.
2. Verify joint/termination kit label and title of the installation instruction.
3. Manufacturer’s recommended process/instructions followed.
4. Physical appearance is acceptable.
Test Equipment Type: Manufacture Model: Serial No.

Remarks :

Name
Signature
Date
LE
Date Page : 1 of 1
Doc. No. :
Rev. :
:
Sub-System No:
e Rating:
o:
V DC )
After Splice Joint
Continuity
L1 :
L2 :
L3 :
Shield :
Result REMARKS
N/A
Cal due date:

COMPANY
PROJECT
INSULATION RESISTANCE AND CONTINUITY TEST RECORD ELECTRICAL CAB

Project No. Client :
Main Contractor Sub-Contractor : PT. Amman Mineral Industry
: JGC Indonesia
:
Cable Schedule No./Dwg No. :

Manufacturer: Test Voltage: VDC
Insulation
Three Phase
Rated
No. Cable Drum No Cable Type No. of Cores& Size L1- All other L2- All other cores/ Armour/E
voltage
Continuity
cores/ Armour/E
1
2
3
4
5
6
7
8
9
10
Test Equipment Type Manufacture Model No
Remarks :
Prepared by,
SUBCONTRACTOR
Name
Signature
Date
ITR-4000-204
UNIT (ASU) Contract No. :
RECORD ELECTRICAL CABLE DRUM BEFORE INSTALLATION

Date Page : 1 of 1
Doc. No. Rev. :
:
:
Rev: System No: Sub-System No:

Ambient Temperature: °C
Insulation Resistance of Power Cables (MΩ) IR of Control Cables
(MΩ)
Three Phase Single Phase
L2- All other cores/ Armour/E L3- All other N- All other *Shield- P- All other cores/ Core - Core –
cores/ Armour/E cores/ Armour/E Armour/E Armour/E Core Armour/E
Model No Serial No. Cal Due Date
epared by, Checked / Approved by, Reviewed / Witnessed by,

ONTRACTOR CONTRACTOR COMPANY
61 / 103
ITR-4000-205
AIR SEPARATION UNIT (ASU) Contract No. :

PROJECT
INSPECTION INSTALLATION OF CONDUIT

Project No. :
Date :
Client : PT. Amman Mineral Industry Page : 1 of 1
Sub-Contractor :
Tag No : System No : Sub-system No :
Tag Desc. : System Desc. : Sub-system Desc. :
Layout Drawing No : Rev :
Area/Location : Building No :
From : To :
RESULT
NO. CHECK DESCRIPTION
YES NO N/A
1 Check for material in accordance to project specification, verify quality and condition.
2 Support spaced/secured according to installation drawings.
3 Sizing as per layout drawings.
4 Routing as per layout drawings.
5 Spacing from other conduits/tray in accordance to specification.
6 Routing clear of hot surface.
7 Check expantion fitting and flexible connections.
8 Check bending radius
9 Conduit sloped properly toward drain fitting
10 Seals, drains, breathers installed wherever specified.
11 Check all conduits are in plumb level.
12 Check protective bushing installed, where applicable.
13 Verify electrical continuity is maintained.
14 Check general workmanship.
15 Touch up paint done as required.
16 Ensure the conduit wall penetration is sufficient

Remarks :

Name
Signature
Date
: 1 of 1
:
Rev :
REMARKS
COMPANY
PROJECT
Contract No. :
INSPECTION INSTALLATION OF LIGHTING AND SMALL POWER DISTRIBUTION BOARD and TEST RECORD

Main Contractor : PT. Amman Mineral Industry Doc. No.
Sub-Contractor : JGC Indonesia
:
Tag No: System No: Sub-System No:

Tag Desc: System Desc: Sub-System Desc:
Area : Building Name / Room No :
Brand: Model No: Serial No:
Rating: Voltage: No. of Circuits:
No: Checks Description Result
YES
1 Verify equipment is appropriate to area classification requirements of the
location as per project specification.
2 Verify panel installation correct as per the drawing.
3 Verify name plate details against drawing/data sheet.
4 Door seals intact.
5 Verify IP rating is maintained.
6 Equipment undamaged.
7 Incoming isolator/fuse switch rating correct.
8 Incoming isolator/fuse switch manual operation satisfactory.
9 All outgoing isolators/fused circuits of correct rating and manual operation

satisfactory.
10 Verify clearances of bus bars are maintained.
11 Equipment earthing done.
12 Ensure all connections are tight and identified.
13 Visually check for correct phase sequence from left to right, top to bottom and front to rear.
14 Circuit identification schedule complete.
15 Verify all labels and tags are correct.
16 Lamp rating, type, colour and position are correct.
17 Unused cable entries are blanked off with correct type of plugs.
18 No unauthorised modifications on electrical enclosures.
19 General condition of enclosure is satisfactory.
20 Enclosure glass parts and glass to metal sealing gasket and/or compounds are satisfactory.
TEST RECORD
: of 2
:
:
No:
Desc:
Result Remarks
NO N/A
PROJECT
Contract No. :
INSPECTION INSTALLATION OF LIGHTING AND SMALL POWER DISTRIBUTION BOARD and TEST RECORD
Project No. : Date :

Client : PT. Amman Mineral Industry Page :
Sub-Contractor :
Insulation Resistance Test (Test Voltage: VDC for 1min.)
Test Result
Configuration
R-YBNE Y-RBNE B-RYNE N-RYBE
YES NO
Result (MΩ)
Test Equipment Manufacture Model Serial No. Cal Due Da

Type
Ambient Temperature: °C
Remarks:
Prepared by, Checked / Approved by, Reviewed / Witnes

Name
Signature
Date
RECORD
of 2
Result
REMARKS
N/A
Cal Due Date

COMPANY
PROJECT
Contract No. :
FUNCTION & PHASE SEQUENCE TEST RECORD

Project No. : Date
Client : PT. Amman Mineral Industry Page
Main Contractor : JGC Indonesia Doc. No.
Sub-Contractor : Rev.
Circuit Description Voltage Protection Type Phase Sequence Result
No: CW CCW YES NO
Test Equipment Type Manufacture Model Serial No: Cal Due Dat
Ambient Temperature: °C Humidity: %

Remarks:

Name
Signature
Date
:
: 1 of 1
:
:
No:
Desc:
ts:
Result
Remarks
N/A
Cal Due Date:

COMPANY
ITR-4000-208
AIR SEPARATION UNIT (ASU) PROJECT Contract No. :
INSTALLATION OF SOCKET OUTLETS
Project No. : Date Page

Client : PT. Amman Mineral Industry Main Contractor Doc. No.
: JGC Indonesia Rev.
Sub-Contractor :
Tag No: Type: System No: Sub-System No:

Equipment Title: Area: Building Name / Room No:
Manufacture: Model No: Serial No:
Rating: Voltage: No. of outlets/Circuits:
No Check Description Result
YES
1 Outlets and junction boxes undamaged.
2 Check IP rating of outlets and junction box enclosures suitable for the area.
3 All outlets and junction boxes earthed correctly.
4 Mounting of outlets satisfactory and location as per the drawing and accessible.
5 Correct connections at each outlet.
6 Visually verify polarity at each outlet.
7 No. of outlets / circuits is correct.
8 Cable terminations satisfactory and identified correctly.
9 Cable correct size and type/Cable glands correct and properly glanded (where applicable).
10 Identification Tags provided.
11 Switch on unit can only be closed with plug inserted.
12 Plug cannot be removed when switch is closed.
13 Verify rating of each outlet is correct.
15 No unauthorised modifications on electrical enclosures.
16 General condition of enclosure is satisfactory.
17 Enclosure flange faces are clean and undamaged and gaskets, if any, any are satisfactory.
18 Flange gap dimensions are within maximal values permitted.
19 Insulation Resistance Test (Test Voltage: VDC for 1min.)
IR Test: (Full Circuit) in Convenience Phase-N Phase-E N-E
MΩ Outlets
Welding Outlets L1-L2 L1-L3 L2-L3 L1-N L2-N L3-N L1-E
Test Equipment Type Manufacture Model Serial No.
Ambient Temperature: °C Humidity: %

Remarks:
Prepared by, Checked / Approved by, Reviewed / Witne

SUBCONTRACTOR CONTRACTOR COMPAN
Name
Signature
Date
00-208
t No. :
Date Page : 1 of 1
Doc. No. :
Rev. :
:
Sub-System No:
Building Name / Room No:
Serial No:
No. of outlets/Circuits:
Result REMARKS
NO N/A
N-E
L2-E L3-E N-E
Cal Due Date

COMPANY
ITR-4000-210
Contract No.
INSPECTION LIGHTING INSTALLATION INSIDE BUILDING

:
Tag No : System No: Sub-System No:

IP Rating: System Desc: Sub-System Desc:
Circuit No: Lighting Type: Area :
Lighting Layout Drawing No: Building Name / Room No :
No. Checks Description Result
YES
1 Check Installation of Lighting switch as per approved drawing
2 Check Installation of Lighting as per approved drawing
3 All fittings solidly and correctly mounted and not obstructed by other services.
4 All equipment undamaged and clean
5 All labeling are correct.
6 Ensure Lamp rating, type and position are correct.
7 No undue accumulation of dust and dirt.
Notes :

Name
Signature
Date
TR-4000-210
:
ILDING
: 1 of 1
:
:
System No:
System Desc:
:
ding Name / Room No :
Result REMARKS
YES NO N/A

COMPANY
PROJECT Contract No.
INSPECTION RECEPTACLE INSTALLATION

:
Tag No : System No: Sub-System No:

IP Rating: System Desc: Sub-System Desc:
Circuit No: Lighting Type: Area :
Lighting Layout Drawing No: Building Name / Room No :
No. Checks Description Result
YES
1 Check Location, elevation and orientation of receptacle as per layout drawing.
2 Ensure type of installed receptacle is corect as per specification
3 Check Circuit Installed and Identified according to approved drawings and specifications.
4 All equipment undamaged, clean and all spare entries blanked of with correctly certified plugs.
5 All labeling are correct.
6 Earth connection and earth continuity in accordance with specification.
7 Check Earth connection and earth continuity are installed properly
9 No undue accumulation of dust and dirt.
10 Where applicable, sealing is satisfactory.
Notes :

Name
Signature
Date
TR-4000-211
:
: 1 of 1
:
:
System No:
System Desc:
:
ding Name / Room No :
Result REMARKS
YES NO N/A

COMPANY
AIR SEPARATION UNIT (ASU) PROJECT ITR-4000-212
Contract No. :
LIGHTING AND RECEPTACLE VOLTAGE CIRCUIT TEST RECORD
Project No. Client : Date Page :

Main Contractor : PT. Amman Mineral Industry Doc. No. :
Sub-Contractor : JGC Indonesia : 1
:
LP Tag No: System No: Sub-System No:

LP Tag Desc: System Desc: Sub-System Desc:
Area: Building Name :
Panel Schedule No: Rev:
Layout Drawing No: Rev:
NO Room No / Name BRANCH CIRCUIT RESULT REMARKS
CIRCUIT NO. VOLTAGE
Test Equipment Type Manufacture Model Serial No. Cal Due D
Remarks:
Prepared by, Checked / Approved by, Reviewed / Wit

SUBCONTRACTOR CONTRACTOR COMPA
Name
Signature
Date
of 1
em No:
em Desc:
REMARKS
Cal Due Date

COMPANY
AIR SEPARATION UNIT (ASU) PROJECT ITR-4000-213
Contract No. :
ILLUMINATION LEVEL MEASUREMENT TEST RECORD
Project No. Client : Date Page Doc. :

Main Contractor : PT. Amman Mineral Industry No. :
Sub-Contractor :
: JGC Indonesia
:
LP Tag No: System No: Sub-System No:

LP Tag Desc: System Desc: Sub-System Desc:
Area: Building Name / Room No:
Layout Drawing No: Rev:
NO. ROOM NAME / NO HEIGHT FROM ILLUMINATION STANDARD JUDG
MEASUREMENT POSITION GROUND LEVEL ( Lux ) ILLUMINATION (Lux) (Accepted
Test Equipment Type Manufacture Model Serial No. Cal Du
Remarks:

SUBCONTRACTOR CONTRACTOR COM
Name
Signature
Date
1 of 1
Sub-System No:
Sub-System Desc:
JUDGEMENT
(Accepted/ Rejected)
Cal Due Date

COMPANY
PROJECT
Contract No. :
INSPECTION OF SYSTEM EARTHING INSTALLATION and TEST RECORD

Project No. Client : Date Page :
Sub-Contractor : JGC Indonesia :
:

Tag Desc.: System Desc.: Sub-System Desc.:
Area: Location:
Drawing No: Rev:
Electrical Lightning Protection Instrument Earth
No: Check Description Result
YES
1 Cable size, type and route as specified in the layout drawings.
2 Depth of underground cable is acceptable.
3 Verify that adequate clearance is maintained between earth cable and other services
(especially for underground cables).
4 Cad weld connections/joints are checked for proper bonding.
5 Connections/joints are insulated properly (where applicable)
6 Check crimping of earthing clamps for proper bonding.
7 Above ground cables are fixed properly to the structure.
8 Clean earth bar assembly, insulators and connections fitted properly.
9 Check proper routing and dressing of the cables.
10 Tags provided as per the drawing (where applicable)
11 Earth electrodes are located as per layout drawing.
12 Earth electrodes are connected properly to the main grid.
13 Earth network disconnected for testing purpose.
14 Continuity between the connection point and adjacent Bar/Grid.
15 Verify cables are reconnected & tightened after test
16 Inspection pit provided and identified.
17 Earth bar located as per layout drawing.
18 Earth bar installation as per installation detail drawing.
19 Earth bar assembly and connections are fitted correctly.
20 All bondings to equipment are in accordance with installation detail drawing.
21 All wire lugs are properly crimped and bolted.
22 All non current carrying metal parts are bonded to earthing system.
23 Earthing Continuity Test Record
Tag Number Cable Continuity Resistance to Earth Grid
From To
nd TEST RECORD
of 2
em No:
em Desc.:
nt Earth
Result REMARKS
NO N/A
PROJECT
C ntract No. :
o
INSPECTION OF SYSTEM EARTHING INSTALLATION and TEST RECORD

Project No. Client : Date :
Main Contractor : PT. Amman Mineral Industry Page :
Sub-Contractor : JGC Indonesia Doc. No. :
:

Area: Location:
Drawing No: Rev:
Electrical Lightning Protection Instrument Earth
No: Check Description Result
YES
24 Earthing Resistance Test Record
Result of resistance measured
( Network )
Rod No.
R1 R2 R3 Avarage Value
Test Equipment Type Manufacture Model Serial No.
Remarks:
- All ground shall have a resistance to earth not exceeding 5 ohm in network connection.

Name
Signature
Date
nd TEST RECORD
of 2
em No:
em Desc.:
nt Earth
Result REMARKS
NO N/A
erial No. Cal Due Date

COMPANY
ITR-4000-215
AIR SEPARATION UNIT (ASU) Contract No. :
PROJECT
INSPECTION OF LIGHTNING PROTECTION SYSTEM INSTALLATION AND TEST RECORD

Project No. Client : Date Page : 1 of
Sub-Contractor : JGC Indonesia :
:

Area: Location:
Drawing No: Rev:
No: Check Description Result REMARKS
YES NO N/A
1 Earth electrodes are located as per layout drawing.
2 Earth electrodes are connected to the main grid.
3 All earth electrodes shown on the above mentioned layout drawing.
4 Inspection pits installed properly.
5 Connections are in accordance to the drawings.
6 Lightning air terminal location and installation is in accordance with drawing.
7 Earth tape and down conductors are installed as per the installation details.
8 Test clamps are fitted properly and disconnect facilities are functional.
9 All bonding to the metallic structures are in accordance with installation details and
layout drawings.
10 Earthing Continuity Test Record
Tag Number Cable Continuity Resistance to Earth Grid
From To
11 Earthing Resistance Test Record

Result of resistance measured
( Network )
Rod No.
R1 R2 R3
Value
Test Equipment Type Manufacture Model Serial No. Cal Due Date
Remarks:
- All ground shall have a resistance to earth not exceeding 5 ohm in network connection.

Name
Signature
Date
D
1
REMARKS
Cal Due Date

/ Witnessed by,
OMPANY
Area / Location Ref. Drawing No : Punch List No

: Unit / Facility
Item Punch List Category

No. Punch List Description A/B/C/D
Note Category Description : : Signifies that the Punch list item, defect, or omission must be repaired or completed before issuance of SYSTEM CO
ABC : Signifies that the Punch list item, defect,or omission may be completed after Construction Completion during Pre-Co
D CERTIFICATE.
: Signifies that the Punch list item, defect, or omission can be repaired and/or completed after System HANDOVER, b
and COMPANY.
: Recognized as an item that is desirable to Operations, but is outside the project work scope agreement, is not opera
"D" items will not prevent HANDOVER, TURNOVER, or ACCEPTANCE.
Prepared As Punch List
Print Name
Signature
Date
Report No :
Doc. No :
PROJECT
Contract No:
Project No:
System / Sub- :
System
Area :
Reference Dwg :
Punch List No :
Unit / Facility :
Punch List Category Target Date Date Accepted

Approved Cleared S/C JGC AMIN Remarks
JGC AMIN
before issuance of SYSTEM CONSTRUCTION COMPLETION CERTIFICATE.

ction Completion during Pre-Commissioning. All Category "B" items must be corrected before issuance of a System HANDOVER
ed after System HANDOVER, but must be done before TURNOVER. Deviations must be agreed to in writing between CONTRACTOR
scope agreement, is not operationally critical to the facility, process, or people, and will be rectified at COMPANY expense. Category
CONTRACTOR COMPANY
Punch List Completed As Punch List Completed
74 / 103
AIR SEPARATION UNIT (ASU) PROJECT Inspection and Test Plan for Building COMPANY No.
0201
HVAC Work CONTRACTOR No. : S-A000-1670-20
Contract No
Contractor : JGC Indonesia Location : Bojonegoro, East Java, Indonesia


V : Verification
Inspection Level
Activity No. Activity Description Reference Documents Acceptance Criteria Verify Doc.
S/C
MATERIAL RECEIVING INSPECTION
Approved Specification, Packing

List / Material Certificate
Approved Specification, Packing List
1.1 Material Receiving Inspection ITR-GEN-001 M
/ Material Certificate
Ducting Installation
Type, Size, Location, Elevation, Support of Ducting
2.1 Approved Design Drawing As per Approved Design Drawing ITR-4000-501 M
Tightness of Connection and Joints, Penetration Condition

As Approved Procedure &
2.2 Approved Procedure & Design Drawing ITR-4000-501 M
Design Drawing,
Check Installation of Accessories (Dampers, Grilles, Diffusers, Flexible Duct, Hanger)

As Approved Procedure &
2.3 Approved Procedure & Design Drawing ITR-4000-501 M
Design Drawing,
Check Insulation
As per Design Drawing, and
2.4 Approved Design Drawing, Specification ITR-4000-508 M
Specification
As per Data Sheet, Specification,

and Approved Procedure
Data Sheet, Specification, Instruction
2.5 Check Installation and Function Test of Damper ITR-4000-502 M
Manual, Approved Procedure
Data Sheet, Specification, Approved As per Data Sheet, Specification,

Procedure and Approved Procedure
2.6 Duct Leak Test ITR-4000-503 M
HVAC Equipment Installation
Installation of Split Type Room Air Conditioner
3.1
a Check Location, Elevation/Leveling, Alignment, Support, and Maintenance Access. As Approved Design Drawing,
Approved Standard Installation.
Approved Design Drawing, Approved
ITR-4000-504 M
Standard Installation.
b. Check the cable termination is correct

Approved Design Drawing, Approved As per Approved Design
Manufacture Drawing and Standard Drawing, Approved Manufacture
Installation. Drawing and Standard ITR-4000-504 M
Installation.
c Ensure tagging already installed is correct & proper
Approved Drawing As per Approved Drawing ITR-4000-504 M
d Insulation Resistance Measurement

Refer to ITP Elevtrical
Work For Building
Approved Specification As Approved Specification M
3.2 Installation of Fan
a Check Location, Elevation/Leveling, Alignment, Support, and Maintenance Access. As Approved Design Drawing,
Approved Standard Installation.
Approved Design Drawing, Approved
ITR-4000-505 M
Standard Installation.
b. Check the cable termination is correct
Approved Design Drawing, Approved As per Approved Design
Manufacture Drawing and Standard Drawing, Approved Manufacture
Installation. Drawing and Standard ITR-4000-505 M
Installation.
c Ensure tagging already installed is correct & proper
Approved Drawing As per Approved Drawing ITR-4000-505 M

COMPANY No. : ACCS-40-411-AS01-S-PLN-
0201
Contract No :
Rev.2A
Inspection Level
REMARKS
JGC AMIN
W,R R
W,R SW , R
W,R SW , R
W,R SW , R
W,R SW , R
W,R SW , R
W,R SW , R
W,R SW , R
W,R SW , R
W,R SW , R
W,R SW , R
W,R SW , R
W,R SW , R
W,R SW , R
AIR SEPARATION UNIT (ASU) PROJECT Inspection and Test Plan for Building COMPANY No.
0201
HVAC Work CONTRACTOR No. : S-A000-1670-20
Contract No
Contractor : JGC Indonesia Location : Bojonegoro, East Java, Indonesia


H V : Hold Point M : Monitor AMIN : PT. Amman Mineral Industry
: Verification
Inspection Level
Activity No. Activity Description Reference Documents Acceptance Criteria Verify Doc.
S/C
Refrigerant & Drain Piping installation
4.1 Type, Size, Location, Elevation, Support of Piping Approved Design Drawing As per Approved Design Drawing ITR-4000-506 M
As Per Specification, and

4.2 Piping Pressure Test Specification and Approved Procedure ITR-4000-507 M
Approved Procedure
As per Approved Design

4.3 Insulation Check Approved Design Drawing, Specification ITR-4000-508 M
Drawing, and Specification
Design Drawing, Data Sheet, Specification, As per Design Drawing, Data

5 Final Inspection release ITR-4000-509 M
Approved Procedure Sheet, Specification
COMPANY No. : ACCS-40-411-AS01-S-PLN-
0201
Contract No :
Rev.2A
Inspection Level
REMARKS
JGC AMIN
W , R SW , R
R R
W,R SW,R
W , R SW
ITR LIST
No Description
1 Material Receiving Inspection Report
2 HVAC Ducting System Installation
3 Damper Installation and Test
4 Duct Leak Test
5 Split Type Room Air Conditioner Installation
6 Fan Installation
7 Piping Installation Check
8 Pressure Test Record
9 Piping Insulation Inspection report
10 Final Inspection
ITR
ITR-GEN-001
ITR-4000-501
ITR-4000-502
ITR-4000-503
ITR-4000-504
ITR-4000-505
ITR-4000-506
ITR-4000-507
ITR-4000-508
ITR-4000-509
PROJECT
REQUEST FOR INSPECTION (RFI) RFI. No
Issue Date :
:
Attn : Mr……. Rev No :
Project Construction Manager Mech. Static Mech. Rotating
Project Title : AIR SEPARATION UNIT (ASU) PROJECT Remarks
Gentlemen,
Civil Telecommunication Instrument
Piping Electrical Pipeline
Date and time Place / Area Inspection Item
Comments :

Print Name
Signature
Date

Location Reff.Dwg.
d. Supplier / Manufacture Name :
f. Datasheet No :
h. Packing List :
NO DESCRIPTION QTY CONFORMANCE TO SPECT.

YES

Print Name
Signature
Date
ITR-GEN-001
Doc.No.:
Contract No :
Project No : Rev.2A

NFORMANCE TO SPECT. REMARKS

NO

CONTRACTOR COMPANY
79 / 103
PROJECT Doc.No : Contract No:
Subject : HVAC Ducting System Installation Project No :

Rev.2A
Date :
Client : PT. Amman Mineral Industry RFI No :
General
a. Area/Building Name :
b. System / Sub-System :
c. Part/ Location :
d. Reference Drawing/Specification :
e. Equipment Tag Number :
f. Manufacturer Name :
g. Model Number :
h. Serial Number :

1 Tag identification is correctly as per inspection drawing
2 Check the Type and Size of Ducting is correct
3 Check ductwork and all associated equipment undamaged, clean and in good
condition
4 Flexible connection correctly fitted and do not take up offsets
5 Isolation materials included between supports and ducts correctly installed.
6 Ensure Hanger and Support already installed in properly & in correct position
7 Bird screens fitted to inlets and all bolting secured.

8 Check all connection: Tightness, joint gaskets fitted correctly and stress free
9 All Duct are internally Clean

10 Access to inspection/test place is clean and tidy before and after test.
11 Check Earthing / Bonding already done properly
Ducting Accessories Installation Record

Size & Joint Result
No Tag No Item Thickness Ducting Type Room Elevation
Bolting Gasket Sealed Acc Rej
Ducting Support Installation Record

Hanger Result
No Ducting Size Room
Spacing Trapeze Acc Rej
Remarks :
Print Name
Signature
Date
ITR-4000-502

PROJECT
Subject : Damper Installation and Test Rev.2A

Date :
Client PT. Amman Mineral Industry RFI No :
General
c. Part/ Location
f. Manufacturer Name
g. Model Number
h. Serial Number
1 Nameplate / Tag no. plate fitted. Details are correct to specification and drawings.
2 Check damper installation correct to design specification and drawings.
3 Check damper and all associated equipment undamaged, clean and in good condition.
4 Visually inspect damper for completeness.
5 Check damper internals are clean and free of debris
6 Access space available for inspection, maintenance and equipment removal.
7 Ensure equipment guards in place and securely fixed.
8 Damper blades move freely.
9 Blades close properly, adjustment level operates satisfactory.
10 Blade position external indication fitted and correct
11 Blade position locking quadrant satisfactory.
Remarks :

Print Name
Signature
Date
Rev.2A
REMARKS
ITR-4000-503
Subject : Duct Leak Test Rev.2A

Client : PT. Amman Mineral Industr RFI No :
General
a. Area / Building Name :
b. System / Sub-System :
c. Part/ Location :
d. Reference Drawing / Specification :
e. Air System :
f. Leakage Class :
g. Fan CFM :
h. Specified Test Pressure :
i. Duct Construction Pressure :
DESIGN DATA FIELD DATA RECORD RESULT
Subject / Type of Allowable CFM (Test Duration Diameter Pressure

Duct Leakage Section)
Surface Area Date Actual CFM ACC REJ
Orifice Tube Duct Across
Orifice
Remarks :

Print Name
Signature
Date
Rev.2A
RESULT
REMARKS
N/A
Subject : Split Type Room Air Conditioner Installation Rev.2A

Date :
General
c. Part/ Location
g. Model Number
h. Serial Number

1 Check Location, Leveling and Elevation is correct as per drawing
2 Ensure the Indoor Unit & Outdoor Unit is installed in proper support and
Fixed
3 Ensure the tagging already installed
4 Check tubing connection of tubing is proper
5 Check the tubing installed is correct type and size
6 Ensure no leakage at all connections
7 Ensure all electrical connection is secured tightly on its proper post
8 Ensure the drain hose is installed properly
9 Check Cleanliness
Remarks

Print Name
Signature
Date
Rev.2A
Remarks
Subject : Fan Installation Rev.2A

Date :
General
c. Part/ Location
g. Model Number
h. Serial Number

1 Name plate / Tag Identification is Correct to Specification and Drawing
2 Check Location, Leveling and Elevation is correct as per drawing
3 Ensure the fan & motor is installed correctly and all accessories
4 Check unit and all associated equipment undamaged, clean and in good condition
5 Anti Vibration Mounts Installed Correctly

6 Access Space Available for Maintenance and Equipment Removal
7 Flexible connection between duct and unit tight and secured
Verify that the unit’s protective terminal(s) are properly connected to a suitable grounding
8 point. Ensure that all unit internal ground connections are
tight.
Remarks

Print Name
Signature
Date
Rev.2A
Remarks
Form.No : ITR-4000-506 Report
Rev : 2A Project No : Contract No : Date
CLIENT : PT. Amman Mineral Industry Pages No. :
Subject : PIPING INSTALLATION CHECK
SYSTEM / Sub-SYSTEM No : Area :
Ref. Drawing No. : Equipment No. :
CHECKED ACCEPTED
NO. ITEMS / DESCRIPTION
YES N/A S/C CONT COMPANY
1 Correct pipe support , location / type / size /material
2 Penetration on Wall / Roof / Floor
3 Soldering / Brazing of Joint
4 Surface Condition
5 Type of Insulation
6 Insulation Installation
RESULT: ACCEPTED REJECTED
Prepared / Inspected by, Checked / Approved by, Reviewed / Witnessed by
NAME
SIGNATURE
DATE
No :
Pages No. :
ED
REMARKS
COMPANY
Reviewed / Witnessed by
COMPANY
Form.No : ITR-4000-507
Rev : 2A Project No : Contract No :
CLIENT : PT. Amman Mineral Industry
Subject : PRESSURE TEST RECORD
SYSTEM / Sub-SYSTEM No : Area

:
Ref. Drawing No. : Equipment No. :
PRESSURE TEST
Test Pressure (psi) Duration (minutes)
Circuit Description / Number Test Fluid
Rated Actual Rated Actual
REMARKS
Prepared / Inspected by, Checked / Approved by, Reviewed / Witnessed by
Name
Signature
Date
Report No :
Date :
ation (minutes)
Test Result
Actual
Reviewed / Witnessed by
COMPANY
Subject : PIPING INSULATION INSPECTION REPORT

Project : AIR SEPARATION UNIT (ASU) PROJECT Date
:
Surface Insulation
Cleaning material
No Line No Insulation Spec
Result: Accepted
Calibration Details : Rejected
Prepared by
SUBCONTRACTOR
Print Name
Signature
Date
ITR-4000-508
Report No Contract No:
UNIT (ASU) PROJECT
Rev.2A
:
RFI No :
Insulation Thickness / No. of

layers
Vapor Barrier Metal Jacketing Remarks
Checked/Approved by Reviewed/Witnessed by
CONTRACTOR COMPANY
87 / 103
PROJECT Doc.No :
Contract No:
Subject : Final Inspection Project No :

Date :
Client : PT. Amman Mineral Industry RFI No
:
General
c. Part/ Location
We certify the scope of work defined in the above mentioned ITP is completed and is verified in accordance with
attached list of ITR’s.
All acceptance criteria described in the above mentioned ITP are met.
STATUS
No Activities
Complete Not Complete
1 Ducting Installation
2 Installation of Split Type Room Air Conditioner
3 Installation of Fan
4 Refrigerant & Drain Piping installation

Print Name
Signature
Date
Rev.2A
TUS
Remarks
N/A
88 / 103
Area / Location Ref. Drawing No : Punch List No Unit /

: Facility
Item Punch List Description Punch List Category

No. A/B/C/D Approved
JGC AMIN
Note Category Description : : Signifies that the Punch list item, defect, or omission must be repaired or completed before issuance of SYSTEM CONSTRUCTION COMPLETION CE
ABC : Signifies that the Punch list item, defect,or omission may be completed after Construction Completion during Pre-Commissioning. All Category "B" item
D CERTIFICATE.
: Signifies that the Punch list item, defect, or omission can be repaired and/or completed after System HANDOVER, but must be done before TURNOVE
COMPANY.
: Recognized as an item that is desirable to Operations, but is outside the project work scope agreement, is not operationally critical to the facility, proces
items will not prevent HANDOVER, TURNOVER, or ACCEPTANCE.
Print Name
Signature
Date
Report No :
Doc. No :
Contract No:
Project No: Rev. 2A
System / Sub- :
System
Area :
Reference Dwg :
:
:
Target Date Accepted Remarks

Date Cleared S/C JGC AMIN
EM CONSTRUCTION COMPLETION CERTIFICATE.

Pre-Commissioning. All Category "B" items must be corrected before issuance of a System HANDOVER
VER, but must be done before TURNOVER. Deviations must be agreed to in writing between CONTRACTOR and
operationally critical to the facility, process, or people, and will be rectified at COMPANY expense. Category "D"
RACTOR COMPANY
AIR SEPARATION UNIT (ASU) INSPECTION AND TEST PLAN FOR B
PROJECT FIRE ALARM
A : Approval
W : Witness
SW : Spot Witness JGC : JGC Indonesia
H : Hold Point
P : Provide AMIN : PT. Amman Mineral Industry
V : Verification
M : Monitor/Surveillance
Reference Document
Activity No. Activity Description
INSTALLATION FOR ELECTRICAL CABLES (INSIDE BUILDING)

1
PREPARATION
Data Sheet, Factory test report, Material certificate,

1.1 Material receiving inspection Packing List, IRC
Insulation Resistance /Continuity tests and Inspection of cables before Cable drum schedule/cable schedule, Manufacturer ’s
1.2 installation (on drum ) at warehouse, prior to release to site for instructions
installation
INSTALLATION & TESTING
Inspection of above ground cable
1.3 Check Conduit Installation Approved Procedure & Design Drawing
1.4 Check Cable glanding Approved Procedure & Design Drawing
1.5 Check Cable Termination Approved Procedure & Design Drawing
Insulation Resistance and Continuity test after glanding and termination

1.6 Approved Procedure & Design Drawing
1.7 Check Cable Identification/markers Approved Procedure & Design Drawing
INSTALLATION FOR FIRE ALARM CONTROL PANEL

2
PREPARATION

2.2 Installation Check Installation details, Layout drawing
2.3 Check Mounting & Alignment Installation details, Layout drawing
2.4 Earthing Connection Check Installation details, Layout drawing

2.5 Check cable connection and tagging correct Installation details, Layout drawing
Installation details, Approved Procedure, Layout drawing

2.6 Testing
ION AND TEST PLAN FOR BUILDING COMPANY No
ARM CONTRACTOR No
CONTRACT No
al Industry
Acceptance Criteria Verify Doc. Inspection Level

REMARKS
S/C JGC AMIN
Comply to Data Sheet, Factory test report, Material

certificate, Packing List, IRC ITR-GEN-001 M W, R R
Complied with approve drawings and Installation Detail Refer to ITP Building
Electrical M W R
Refer to ITP Building

As Approved Procedure & Design Drawing, Electrical M W, R SW





Complies with approved drawings, installation details

ITR-4000-301 M W, R SW

ITR-4000-301 M W, R SW

ITR-4000-301 M W, R SW
ITR-4000-301 M W, R SW
Complies with approved drawings, installation details Commissioning Report

M W, R SW Commissioning Stage
AIR SEPARATION UNIT (ASU) INSPECTION AND TEST PLAN FOR B
PROJECT FIRE ALARM
A : Approval
W : Witness
SW : Spot Witness JGC : JGC Indonesia
H : Hold Point
P : Provide AMIN : PT. Amman Mineral Industry
V : Verification
M : Monitor/Surveillance
Reference Document
Activity No. Activity Description
INSTALLATION FOR HEAT & SMOKE DETECTORS

3
PREPARATION


3.3 Testing
4 INSTALLATION FOR MANUAL ALARM CALL POINT
PREPARATION

Testing Installation details, Approved Procedure, Layout drawing
INSTALLATION FOR ALARM BELL

5
PREPARATION


Testing
INSTALLATION FOR ALARM HORN STROBE AND BEACON

6
PREPARATION

6.3 Testing Installation details, Approved Procedure, Layout drawing

ION AND TEST PLAN FOR BUILDING COMPANY No
ARM CONTRACTOR No
CONTRACT No
al Industry
Acceptance Criteria Verify Doc. Inspection Level

REMARKS
S/C JGC AMIN


ITR-4000-302 M W, R SW

M W,R SW Commissioning Stage

certificate, Packing List, IRC ITR-GEN-001 M W,R R

ITR-4000-303 M W, R SW
Complies with approved drawings, installation details Commissioning Report M W,R SW Commissioning Stage
92 / 103


ITR-4000-304 M W, R SW
M W,R SW Commissioning Stage


ITR-4000-305 M W, R SW
Complies with approved drawings, installation details Commissioning Report M W,R SW Commissioning Stage
93 / 103
ITR LIST
No ITR Description
1 MATERIAL RECEIVING INSPECTION REPORT
2 INSTALLATION CHECK FOR FIRE ALARM CONTROL PANEL
3 INSTALLATION CHECK SHEET FOR DETECTORS
4 INSTALLATION CHECK SHEET FOR MANUAL CALL POINT
5 INSTALLATION CHECK SHEET FOR ALARM BELL
6 INSTALLATION CHECK SHEET FOR HORN AND BEACON

Verify Doc.
ITR-GEN-001
ITR-4000-301
ITR-4000-302
ITR-4000-303
ITR-4000-304
ITR-4000-305
94 / 103

Location Reff.Dwg.
f. Datasheet No :
h. Packing List :
NO DESCRIPTION QTY CONFORMANCE TO SPECT.

YES

Print Name
Signature
Date
ITR-GEN-001
Doc.No.:
Contract No :
Project No :

FORMANCE TO SPECT. REMARKS

NO

CONTRACTOR COMPANY
95 / 103
ITR-4000-301

PROJECT
Subject : INSTALLATION CHECK FOR FIRE ALARM CONTROL PANEL Project No : Rev.2A
Project AIR SEPARATION UNIT (ASU) PROJECT Date :

Client PT. Amman Mineral Indus RFI No :
General
c. System Description
d. Part/ Location
e. Reference Drawing/Specification
f. Equipment Tag Number
g. Tag Description
h. IP Rating
No Activities Accept Reject N/A Remarks

1 Check that panel board identification tag is correct and in accordance with drawings
2 Check the panel installed as per drawing
3 Check the panel dimension and elevation are as per drawing
4 Check the circuits are served by correctly-sized breakers and/or fuses
5 Verify that Power Earthing (PE) are correctly installed and terminal points are tightened
6 Verify that Instrument Earthing (IE) are correctly installed and terminal points are tightened
7 Verify that grounded conductors (neutrals) are correctly installed and terminal points are
tightened
8 Confirm Cable Entry and glanding are glanded /sealed properly.
9 Check the cable size for all incoming and outgoing cables is as per drawing
10 Check the Cable Marking & Core Marking are as per the drawing
11 Check that panel board is securely mounted and all the base bolt is installed
12 Check the Terminal Block ID and Number is installed as per approved shop drawings
13 Check the terminal block and connection points are secured properly
14 Panel board is clean and free from dust and paint
15 Ensure the grounding already installed properly
16 Check the IP Rating panel is correct as required
17 Ensure all unused cable entry already plug off properly
18 Ensure the panel door can fully open without any interfere with others
19 Ensure the circuit schedule is correct
Remarks
Print Name
Signature
Date
ITR-4000-302

PROJECT
Subject : INSTALLATION CHECK SHEET FOR DETECTORS Project No :
Project :AIR SEPARATION UNIT (ASU) PROJECT

Date RFI No :
Client : PT. Amman Mineral Indu :
General
d. Part/ Location
g. Tag Description
h. IP Rating
No Activities Accept Reject N/A

1 Check type of detector as per approved material & drawing
2 Check location of detector as per approved drawings
3 Ensure the elevation & orientation are correct as per approved drawing
4 Ensure the IP Rating is correct as per datasheet
5 Check tag number of detector as per approved drawings
6 Check the material is undamaged
7 Check that the cable is correctly plugged to respective port
8 Ensure the equipment is securely mounted or bracket properly
9 Confirm that all incoming power source cable are installed correctly and secure
10 All equipment are properly grounded
11 Ensure no modification has been done of the equipments

Remarks

Print Name
Signature
Date
ITR-4000-303

PROJECT
Subject : INSTALLATION CHECK SHEET FOR MANUAL CALL POINT Project No :
Project : AIR SEPARATION UNIT (ASU) PROJECT Date RFI No :

Client : PT. Amman Mineral Ind :
General
d. Part/ Location
g. Tag Description
h. IP Rating
No Activities Accept Reject N/A
1 Check type of Manual Call Point as per approved material & drawing
2 Check location of Manual Call Point as per approved drawings
5 Check tag number of Manual Call Point as per approved drawings

9 Confirm that all incoming power source cable are installed correctly and
secure
Remarks

Print Name
Signature
Date
No : Rev. 2A
N/A Remarks
Rev. 2A
Remarks
ITR-4000-304

PROJECT
Subject : INSTALLATION CHECK SHEET FOR ALARM BELL Project No : Rev. 2A

Date RFI No :
Client PT. Amman Mineral Industr :
General
d. Part/ Location
g. Tag Description
h. IP Rating
No Activities Accept Reject N/A Remarks
1 Check type of Alarm Bell as per approved material & drawing
2 Check location of Alarm Bell as per approved drawings
5 Check tag number of Alarm Bell as per approved drawings
12 Check Enclosure glass part and glass to metal sealing gasket / compound are
satisfactory.
13 Check Enclosure flange faces are clean and undamaged.
14 Check flange gap dimensions are within maximal value permitted
15 Equipment is adequately protected against corrosion, weather, vibration and

other adverse factor
16 NO undue accumulation of dust and dirty
Remarks

Print Name
Signature
Date
ITR-4000-305

PROJECT
Subject : INSTALLATION CHECK SHEET FOR HORN AND BEACON Project No

Date :
Client : PT. Amman Mineral Indus RFI No :
General
d. Part/ Location
g. Tag Description
h. IP Rating
No Activities Accept Reject
1 Check type of Horn & Beacon as per approved material & drawing
2 Check location of Horn & Beacon as per approved drawings
3 Ensure the elevation & orientation are correcct as per approved drawing
5 Check tag number of Horn & Beacon as per approved drawings

Remarks

Print Name
Signature
Date
: Rev. 2A
N/A Remarks
Area / Location Ref. Drawing No : Punch List No Unit / :

: Facility :
Item Punch List Category Target

No. Punch List Description A/B/C/D Approved Date
JGC AMIN
Note Category Description : : Signifies that the Punch list item, defect, or omission must be repaired or completed before issuance of SYSTEM CONSTRUCTION COMPLETION CER
ABCD : Signifies that the Punch list item, defect,or omission may be completed after Construction Completion during Pre-Commissioning. All Category "B" items
CERTIFICATE.
: Signifies that the Punch list item, defect, or omission can be repaired and/or completed after System HANDOVER, but must be done before TURNOVER
: Recognized as an item that is desirable to Operations, but is outside the project work scope agreement, is not operationally critical to the facility, process
Print Name
Signature
Date
Report No :
Doc. No :
Contract No:
Project No:
System / Sub- :
System
Area :
Reference Dwg :
Target Date Accepted

Date Cleared S/C JGC AMIN Remarks
ONSTRUCTION COMPLETION CERTIFICATE.

ommissioning. All Category "B" items must be corrected before issuance of a System HANDOVER
but must be done before TURNOVER. Deviations must be agreed to in writing between
ationally critical to the facility, process, or people, and will be rectified at COMPANY expense.
COMPANY
101 / 103
DRAWING & DOCUMENT
COMMENT RESOLUTION LOG
Title CRL of Site Inspection Test Plan For Building (Drg. No. ACCS-40-411- AS01-S-PLN-
0201)
Vendor Name JGC Indonesia
1A 28-Aug-2022 Commented AMIN
TCE MSR
Rev. Date Status DIS PR ME EL IC CV ST ENV
Reviewed by
Note: Commented/Approved conveyed herein neither relieves Vendor/Contractor of his contractual obligations and his
responsibilities for correctness of dimension materials of construction weights, quantities, design details, assembly fits
system/performance requirement and conformity of supplies with statutory laws as may be applicable, nor does it limit the
Purchaser’s rights under the contract.
OG
CCS-40-411- AS01-S-PLN-
SME
gations and his

assembly fits
able, nor does it limit the
102 / 103
DRAWING & DOCUMENT COMMENT
RESOLUTION LOG
900 KTPA AMIN Captive Copper Smelter Project

Rev. No. 1A
Date of submission 22-Aug-2022
Date of comment 28-Aug-2022
Sr No AMIN Observations/Comments
1 This document is approved with following comments.

a] Inspection level: We will decide the same at a later stage in
consultation with OWNER.
2 Acceptance criteria: Shall be as per Approved drawings/Relevant

Codes and Technical specifications
Page 1 of 1
WING & DOCUMENT COMMENT Drg/Doc No. ACCS-40-411-AS01-S-PLN-0201
OLUTION LOG
Title: Site Inspection Test Plan For Building
JGC Response Status Remarks
Noted.
In JGC understanding, approved

drawing has been design by
CONTRACTOR and approved by
COMPANY that also refer to
specification and relevant codes.
So in JGC understanding, approved
drawing can represent both of spec and
relevant codes that has been discuss
and agreed by AMIN & JGC so that
approved drawing is enough for
acceptance criteria.
ge 1 of 1 103 / 103

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Air Separation Unit (ASU) Project

2A Hernadi 1-Sept- Agung R. 1-Sep-2022 Riky Novfriska 1-Sep-2022 Issued for Construction

PROJECT Air Separation Unit (ASU) Project

OWNER PT AMMAN Mineral Industri

PMC TATA Consulting Engineers Limited

CONTRACTOR PT JGC Indonesia

Document Title Site Inspection Test Plan For Building

Only valid when sealed

review, reasons as enclosed /

ed for information only.

No Date Revision Page Description Remarks

S-A000-1340-001 ACCS-40-411-AS01-G-SPC-0001 GENERAL SPECIFICATION FOR

o have a dedicated Air

uring construction stage for

er to this procedure and items

l be discussed and established

5.2 Inspection and Test Item

UBCONTRACTOR can proceed with the test /

R’s Inspector must be notified in advance and may be

s as applicable for review and approval.

n and / or testing include reporting.

gory required during construction stage of project

er to document no S- A000-1670-101 (ACCS-40-

PROJECT INTERIOR & EXTERIOR FINISHING WORK CONTRACTOR No. : S-A000-167

Contractor : JGC Indonesia Location : Sumbawa, West Nusa Tenggara, Indonesia

A : Approval R : Review S/C : SUBCONTRACTOR

1.3 Documents review (certificates, etc.) ITR-GEN-001 M R

Approved Specification, Approved Drawing &

3 Wall / Partition Work

3.1 Masonry : Hollow Concrete Block

Mix proportion 1 : 3 (cement : sand) for trassam wall

3.1.5 Alignment and plumbness of walls - Alignment ITR-4000-002 M W

Approved Specification, Approved Drawing &

3.1.11 Grouting / Mortar test Procedure Subcont form report M W

Cleaning Procedure ITR-4000-002 M W

3.2.2 Protections for permanent finishes and fittings Procedure ITR-4000-003 M W

- Horisontal 300 mm bottom from ceiling elevation and

- Straightness & flatness : 80 gr thick of paper not pass

3.2.11 Cleaning around permanent finishes and fittings Procedure ITR-4000-003 M W

3-Feb-2012 Mortar test Procedure Subcont form Report M W

Curing at least carried out of 7 days, 2 times each day ITR-4000-003 M W

3.3 Tile Work (Wall)

3.3.6 Corner, plinth and joint beads setting Procedure ITR-4000-004 M W

3.3.12 Cleaning and polishing Procedure ITR-4000-004 M W

3.4 Gypsum Board Partition

3.4.2 Layout, elevation and marking Approved Drawing ITR-4000-005 M W

3.4.3 Location and size of wall openings Approved Drawing ITR-4000-005 M W

3.4.4 Alignment, spacing and rigidity of runners / studs - Alignment ITR-4000-005 M W

3.4.7 Insulation board / blanket installation Procedure ITR-4000-005 M W

3.4.12 Seal for penetrations of fire rated wall

4.1 Tile Work (Floor)

4.1.6 Corner and joint beads setting Procedure ITR-4000-006 M W

4.1.10 Check adhesion of tiles by sounding Procedure ITR-4000-006 M W

CONTRACTOR No. : S-A000-1670-201

PROJECT INTERIOR & EXTERIOR FINISHING WORK CONTRACTOR No. : S-A000-167

Contractor : JGC Indonesia Location : Sumbawa, West Nusa Tenggara, Indonesia

A : Approval R : Review S/C : SUBCONTRACTOR

4.2 Raise Floor

4.2.2 Conditions of sub floor Procedure ITR-4000-007 M W

4.2.8 Treatment of cut panel edges Procedure ITR-4000-007 M W

4.2.9 Expansion gap at all abutments with seal Procedure ITR-4000-007 M W

4.2.10 Seal for penetrations of floor panels Procedure ITR-4000-007 M W

4.2.11 Electrical continuity and earth bonding Approved Drawing ITR-4000-007 M W