S-000-1310-101-Rs-00077 Site Inspection and Test Plan (Itp) For Civil Work

COMPANY DOCUMENT NO.
JOB CODE REV.

SLTR-S-000-1310-101
CONTRACTOR DOCUMENT NO.
0-0831-00-0000 1A
S-000-1310-101
PAGE 1 OF 6
SUMBAWA LNG TERMINAL &

REGAS FACILITY
CLASS [2]
SITE INSPECTION AND TEST PLAN (ITP)

FOR CIVIL WORK
FOR REVIEW
REV. DATE PAGE DESCRIPTION PREP’D CHK’D APP’D CPY APP’D
1A 18-Jan-23 All Issued for Review R. Setiawan Anthonius F.T Subekti
DM02S3
THIS DOCUMENT / DRAWING INCLUDING ATTACHEMENT EMBODIES PROPRIEATRY INFORMATION OF MEDCO SUMBAWA GAS IN ANY FORM OR MEDIUM TO THIRD
J-20-Jan-2
PARTIES, OR USED FOR OTHER THAN THE PURPOSE FOR WHICH IT HAS BEEN PROVIDED IN WHOLE OR IN PARTY IN ANY MANNER EXCEPT AS EXPRESSLY
PERMITTED BY MEDCO SUMBAWA GAS
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SUMBAWA LNG TERMINAL & REGAS FACILITY S-000-1310-101
SITE INSPECTION AND TEST PLAN (ITP) FOR CIVIL WORK Page 2 of 6
RECORD OF REVISION
The revision listed below have been incorporated in this copy of the document.
REV PAGE
SECTION DESCRIPTION OF CHANGES
NO NO.
DM02S3
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PARTIES OR USED FOR OTHER THAN THE PURPOSE FOR WHICH IT HAS BEEN PROVIDED IN WHOLE OR IN PARTY IN ANY MANNER EXCEPT AS EXPRESSLY
PERMITTED BY MEDCO SUMBAWA GAS.
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CONTENTS
1. INTRODUCTION ................................................................................................................... 4
2. PURPOSE AND SCOPE ....................................................................................................... 4
3. DEFINITION AND ABBREVIATION ...................................................................................... 4
4. REFERENCES ...................................................................................................................... 5
5. RESPONSIBILITIES.............................................................................................................. 5
6. INSPECTION INTERVENTION LEVEL ................................................................................. 6
7. ATTACHMENT ...................................................................................................................... 6
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1. INTRODUCTION
PT Amman Mineral Nusa Tenggara (AMNT) plans to build additional combine cycle power generation
plant for their expansion projects including smelter and other new facilities. To provide gas for those
facilities AMNT engaged PT Medco Sumbawa Gas (MSG) to develop and operate a new LNG Terminal
and Regas Facility within AMNT operation area in Benete Bay of Sumbawa Island, West Nusa
Tenggara, Indonesia.
The project includes facilities of onshore LNG storage tank with capacity of 50,000 m3 and 160,000 m3,
regasification unit to produces up to 77 mmscfd gas, an LNG-Carrier jetty with trestle, utilities, buildings
and gas sendout pipelines to the power plant and smelter.
2. PURPOSE AND SCOPE

The purpose of this document is to ensure that all Construction / Installation of Structure works are
inspected and tested in accordance with the relevant Codes, Standards, Government Regulations,
Procedures and Project Specifications. This document is generic test plan as guideline for
SUBCONTRACTOR to develop the specific inspection plan in accordance with contract scope of work.
This document covers inspection and test items and its intervention point of each party for each work
category during construction stage at site of Sumbawa LNG Terminal & Regas Facility Project for Earth
Work, Concrete Work, Sewer and Drainage, Road Work .
This Site ITP can be adopted by SUBCONTRACTOR subject to approval by CONTRACTOR. All the check
lists and inspection formats reported herein shall be followed by SUBCONTRACTOR to maintain uniformity
in checklists / formats even when a SUBCONTRACTOR is preparing its own Site ITP based on this
document guidelines.
3. DEFINITION AND ABBREVIATION

(1) COMPANY : PT Medco Sumbawa Gas
(2) CONTRACTOR : PT JGC Indonesia
(3) SUB-CONTRACTOR : Any organization who provides service of construction and/or
Installation of Steel Structure and/or Material for the Project.
(4) AMNT : PT Amman Mineral Nusa Tenggara
(5) AMIN : PT Amman Mineral Industri
(6) MIGAS : Directorate of Oil and Gas (Direktorat Jendral Minyak dan Gas
Bumi)
(7) TPIA : Authorized Third Party Inspection Agency of MIGAS
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4. REFERENCES
SLTR-S-000-3115-001
Construction Specification for Earth Works
(S-000-3115-001)
SLTR-S-000-3116-001
Construction Specification for Sewer and Drainage
(S-000-3116-001)
SLTR-S-000-3117-001
Construction Specification for Road and Paving
(S-000-3117-001)
SLTR-S-000-3120-001
Construction Specification for Concrete Works
(S-000-3120-001)
SLTR-S-000-1520-001
Quality Control Execution Plan
(S-000-1520-001)
SLTR-S-000-1670-001
Quality Control Requirement to Subcontractor
(S-000-1670-001)
5. RESPONSIBILITIES
SUBCONTRACTOR 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 and COMPANY shall be responsible to review and approve the ITP submitted by
SUBCONTRACTOR.
When required, the SUBCONTRACTOR’s ITP shall be submitted to MIGAS / TPIA by COMPANY for
determination of their witness or hold points on the inspection and test items during construction /
installation at site.
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6. INSPECTION INTERVENTION LEVEL
Letter Abbreviation Description
CONTRACTOR/COMPANY intends to conduct witness

inspection/test. SUBCONTRACTOR shall submit inspection
H Hold point notification to CONTRACTOR. SUBCONTRACTOR is not
allowed to proceed with the inspection/test unless a written
release is issued by CONTRACTOR.

inspection/test. SUBCONTRACTOR shall submit inspection
notification to CONTRACTOR. However SUBCONTRACTOR
W Witness point
can proceed with the inspection/test when
CONTRACTOR’s/COMPANY’s inspector is not present at the
notified time.

inspection/test by spot/randomly. SUBCONTRACTOR shall
submit inspection notification to CONTRACTOR. However
SW Spot witness
SUBCONTRACTOR can proceed with the inspection/test
when CONTRACTOR’s/COMPANY’s inspector is not present
at the notified time.
Preparation and execution of measurement, observation,

M Implementation
examination or testing and reporting.
SUBCONTRACTOR is requested to submit the documents or

R Record review
inspection records to CONTRACTOR for review.
7. ATTACHMENT
(1) Site Inspection and Test (ITP)
(2) Site Inspection and Test Record (ITR) Form
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ATTACHMENT - 1
Site Inspection and Test Plan (ITP)
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SUMBAWA LNG TERMINAL & REGAS FACILITY
SITE INSPECTION AND TEST PLAN (ITP) FOR CIVIL WORKS

Legend
H : Hold Point M : Implementation JIND : PT. JGC Indonesia
W : Witness Point R : Record Review TPIA : Third Party Inspection Agency Quantum of check
SW : Spot Witness MSG : PT. MEDCO SUMBAWA GAS MIGAS : Direktorat Jendral Minyak dan Gas Bumi
-column to be added
INSPECTION INTERVENTION LEVEL
No. DESCRIPTION REFERENCE DOCUMENT ACCEPTANCE CRITERIA VERIFIED DOCUMENT (RECORD) REMARK
SUBCONT. JEC MEP MIGAS/ TPIA
1 EARTH WORK (Include Road and Paving)

1.1 Excavation
(1) Setting out survey SLTR-S-000-3115-001 As per each drawing ITR-2000-007 M W R -
(S-000-3115-001)
a Calibration of survey instruments R R R
(2) Finishing survey As per each drawing ITR-2000-007 M W R -
(3) Tolerance ITR-2000-007
(3.1) Excavation tolerance SLTR-S-000-3115-001 As per applicable specification M W R -

(S-000-3115-001)
(3.2) Graveled area SLTR-S-000-3117-001 As per applicable specification M W R -

(S-000-3117-001)
1.2 Fill Material

(1) Site Material for Fill SLTR-S-000-3115-001 M W R -
(S-000-3115-001)
(2) Base material for road SLTR-S-000-3117-001 As per applicable specification M W R -

(S-000-3117-001)
(3) Gravel for gravel pave SLTR-S-000-3117-001 Max. particle size = 50mm M W R -
(S-000-3117-001)
1.3 Filling and Compaction

(1) Placement SLTR-S-000-3115-001 M W SW
(S-000-3115-001)
Thickness/per layer Max. 300 mm ITR-2000-009
(2) Compaction (CBR and Density) Not less than 95% of maximum dry ITR-2000-005 M W SW -
density obtained by the modified
proctor test, ASTM D1557
w
(3) Tolerance -
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W : Witness Point R : Record Review TPIA : Third Party Inspection Agency
(3.1) Filling SLTR-S-000-3115-001 As per applicable specification ITR-2000-009 M W R -

(S-000-3115-001)
(3.2) Graveled area SLTR-S-000-3117-001 As per applicable specification M W R -

(S-000-3117-001)
2 CONCRETE WORK
2.1 Material SLTR-S-000-3120-001
(S-000-3120-001)
2.1.1 Material approval
(1) Cement ASTM C 150 and Type I To be stored as per 6.1.2 Material Certificate M R R - Every Delivery
Cement remaining in weather-tight

bulk storage for more than 6
months, or cement in bags in local
storage in the custody of a vendor
for more than 4 months after
completion of tests shall not be
used.
(2) Aggregate ASTM C33 Maximum size of coarse aggregate Material Certificate M R R - Initially for
for structural concrete shall be trial mix,
20mm, except that fireproofing Every Delivery
concrete that shall be 10mm. for Working
Mix
(3) Mixing water ASTM C94 The total sulphur content of the M R R -
water, expressed as PPM by mass of
sulphate ion shall not exceed 1000.
(4) Admixture or additve Section 6.4 Manufacturer certificate/MSDS M R R - Every Delivery
(5) Reinforcing bar Manufacture’s certificate Manufacture’s certificate M R R -
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- Deform rebar SNI-07-2052-2002 Grade BJTS40,

fy=390N/mm2 or ASTM A615/A615M
Grade60
- Plain rebar SNI-07-2052-2002 Grade BJTP24,
fy=235N/mm2 or ASTM A615/A615M
Grade40
- Welded wire fabric SNI-07-0663-1995, fy=490N/mm2 or ASTM
A185/A185M
(6) Anchor bolt By Manufacture’s data report M SW R -
(7) Embedded Steel Applicable drawing, mill certificate M SW R -
(8) Water Stop Manufacture's certificate M SW R -

Applicable drawing
2.2 Concrete Mixing ASTM C94/C94M M R R
(1) Trial mix Per mix design Mix Formula -
(1.1) Slump test SLTR-S-000-3120-001 M W SW -

(S-000-3120-001)
(1.2) Air contents ASTM C138, C173 or C231 M R R -
(1.3) Temperature Max. 38 deg. C M W SW -
(1.4) Compression Test One at 7 days for information, Three ITR-2000-003 M W SW -

at 28 days for determining
acceptability of concrete strength as
per 12.2.4
(2) Working mix M W SW -
(1.1) Slump test SLTR-S-000-3120-001 M W SW -

(S-000-3120-001)
(3) SO3 content Max. 4% by cement wt. -
(4) Temperature Max. 38 deg. C -
(5) Compression test One at 7 days for information, Three ITR-2000-003 M W SW -

at 28 days for determining
acceptability of concrete strength as
per 12.2.4
Concrete design mix detail to be
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Cube sampling/ testing detail to
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2.3 Concrete Foundation
(1) Blinding concrete ITR-2000-001 -
(1.1) Ground condition Clear of loose material M W R -
(1.2) Check of level/Location As per drawing M W R -
(1.3) Thickness Minimum 50 mm M W R -
(2) Re-bar work SLTR-S-000-3120-001 ITR-2000-001 -

(S-000-3120-001)
(2.1) Bar size / Type Drawing M W SW -
(2.2) Number of bar Drawing M W SW -
(2.3) Length Drawing M W SW -
(2.4) Condition of re-bar ACI 117 As per section 8.2.3 M W SW -
(2.5) Splicing ACI 117 Drawing M W SW -
(2.6) Spacing ACI 117 As per drawing M W SW -
(2.7) Hook ACI 117 As per drawing M W SW -
(2.8) Minimum cover M W SW -
Cast-in place concrete (non re- SLTR-D-000-1310-001 Cast against and permanently
stressed) (D-000-1310-001) exposed to earth:
Cast-In-situ bored pile : 100mm
Retaining wall, Anchor block : 75mm
Exposed to Earth/ Weather :

2.9 Anchor bolt /Embedded Footing, Pit : 50mm
item/pocket etc
All other structure
ACI 117
Rebar D19 and bigger : 50mm
Rebar D16 and smaller, wire : 40mm
Not exposed to Weather nor in

Contact with the ground :
Beam, Column : 40mm
Slab, Wall, Joist : 30mm
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(2.9) Allowable tolerance for installation of re- SLTR-S-000-3120-001 As per reference document M W SW -
bar (S-000-3120-001)
ACI 117
2.4 Concrete Pave

(1) Polyethylene sheet SLTR-S-000-3117-001 Polyethylene sheet: at least 0.15 ITR-2000-006 M W SW -
(S-000-3117-001) mm thickness
(1.1) Grounding condition Clear of loose material M W SW -

(1.2) Check of level As per drawing M W SW -
(1.3) Overlap Minimum 150 mm M W SW -
(2) Reinforcing mesh SLTR-D-000-1317-002 Coated WWF per SNI 07-0663-1995 ITR-2000-006
(D-000-1317-002) fy=490 N/mm2 or ASTM
A185/A185M, or equivalent
(2.1) Size, Type dia. 6-150X150 M W SW -
(2.2) Over-lap At least 150mm laying at right-angle M SW SW -
to the edges to be lapped
(2.3) Condition of mesh Clear and free from mill scale grease M SW SW -
and concrete
(2.4) No of spacer blocks Max. 1 m spacing M SW SW -
(2.5) Cover Heavy duty : 40mm top and bottom ITR-2000-006 M SW SW -
Light duty : 40mm top
(3) Joint SLTR-S-000-3117-001

(S-000-3117-001)
(3.1) Check spacing As per drawing M W SW -

(3.2) Sealant SLTR-D-000-1310-001 M W SW -
(D-000-1310-001)
(4) Concrete work SLTR-S-000-3120-001 M W SW -
(S-000-3120-001)
(5) Curing SLTR-S-000-3120-001 To be maintained wet at least 5 M SW SW -
(S-000-3120-001) days
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3 FORM WORK SLTR-S-000-3120-001 (S-000-3120-001) ITR-2000-001 M SW SW

W
ACI 117
(1) Preparation of form surface As per reference document M SW SW -
(1) Removal of forms As per reference document M SW SW -
4 ANCHOR BOLT/EMBEDDED PLATE ACI 117 and Section 13.1.4 ITR-2000-001

(1) Size, Type, Number As per drawing M W SW -
(2) Location, Elevation Location +3mm, -3mm M W SW -

Projection +7mm, -0mm
(3) Firmly support Adequate M W SW -
(4) Protection from corrosion and damage M W SW -
5 CONCRETE WORK SLTR-S-000-3120-001 (S-000-3120-001) and ACI 301

(1) Construction Joint Adequate roughened and clean M SW SW -
(2) Vibrator Ensure vibration is adequate M SW SW -
(3) Free height of discharge Max. 1.5 m M SW SW -
6 FINISHING SLTR-S-000-3120-001 (S-000-3120-001)

As per reference document M SW SW
ACI 301
7 CURING SLTR-S-000-3120-001 (S-000-3120-001) As per reference document
M SW SW
8 POST CONCRETING (as necessary)

(1) Repair of surface defect SLTR-S-000-3120-001 As per reference document ITR-2000-008 M W SW -
(Contractor ID: S-000-3120-001)
ACI 301
(2) Holes of tie-rods SLTR-S-000-3120-001 As per reference document ITR-2000-008 M W SW -
(S-000-3120-001)
9 PILING (NOT APPLICABLE)
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10 SEWER AND DRAINAGE

10.1 Material SW
(1) Underground Gravity Piping Material - Packing list Complete as per Packing list and No ITR-1000-004 M SW R
- Inspection Release Certificate Defect
(1.1) Reinforced concrete pipe M R R
(1.3) Carbon steel pipe M R R
(2) Wrapping material - Packing list

- Inspection Release Certificate
(2.1) Priming Complete as per Packing list and No ITR-1000-004 M R R
Defect
(2.2) Outer wrapping M R R
10.2 Installation of Piping SLTR-S-000-3116-001 (S-000-3116-001)
(1) Excavation for trenching Drawing As per Drawing
(1.1) Setting out survey Drawing As per Drawing M W SW
(1.2) Pipe bedding SLTR-S-000-3116-001 (S-000-3116-001) SLTR-D-000-1316-001 (D-000-1316- M W SW

001)
(2) Pipe laying SLTR-S-000-3116-001 (S-000-3116-001) ITR-1000-001
(2.1) Pipe installation SLTR-S-000-3116-001 (S-000-3116-001) Level of upstream shall be higher M W SW

than the on of downstream.
Elevation: within plus or minus 25
mm
W
(3) Pipe jointing SLTR-S-000-3116-001 (S-000-3116-001) ITR-1000-001 M W SW
(3.1) Welder qualification SLTR-S-000-1670-007 (S-000-1670-007) ASME IX M R R

(Welder / Welding Operator Control SW
Procedure for Construction)
(3.2) Welding Procedure Specification & PQR SLTR-S-000-1670-008 / S-000-1670-008 ASME IX M R R
(Welding Control Procedure for
Construction)
(3.3) Visual Welding Inspection Welding Procedure Specfication As per ASME M W SW
Isometric Drawing
(3.4) Painting (Touch up) and Wrapping SLTR-S-000-13A0-001 (S-000-13A0-001) ITR-1000-001 M W SW
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(4) Backfilling SLTR-S-000-3115-001 (S-000-3115-001) SLTR-D-000-1316-001 (D-000-1316- ITR-1000-001 M W SW

001)
10.3 Leak Test
(1) Water filling test to pipe SLTR-S-000-3116-001 (S-000-3116-001) As per reference document and ITR-1000-001 M W W
drawing
(2) Water filling test to pit SLTR-S-000-3120-001 (S-000-3120-001) As per reference document and ITR-1000-001 M W W
drawing
(3) Holiday test (if coated/wrapped) As per reference document and ITR-1000-001 M W SW
drawing
11 ROAD WORK
11.1 Material Receiving
(1) Sub-base course materials, Base course
materials
(1.1) Specification & size, Volume, Quantity SLTR-S-000-3117-001 (S-000-3117-001) As per reference document ITR-1000-004 M W SW
11.2 Excavation
(1) Setting out survey
(1.1) Line, Grade, and Elevation SLTR-S-000-3115-001 (S-000-3115-001) and SLTR-S-000-3115-001 (S-000-3115- ITR-2000-007 M W SW
Drawing 001) and Drawing
(2) Finishing survey
(2.1) Width, Length, and Depth Drawing As per Drawing ITR-2000-007 M W SW
(3) Tolerance of Excavation
(3.1) Width, Length, and Depth SLTR-S-000-3115-001 (S-000-3115-001) and SLTR-S-000-3115-001 (S-000-3115- ITR-2000-007 M W SW
Drawing 001) and Drawing
11.3 Sub-base coarse

(1) Sub-base coarse Filling SLTR-S-000-3117-001 (S-000-3117-001) As per reference document ITR-1000-005 M W SW
(2) Sub-base coarse Compaction SLTR-S-000-3117-001 (S-000-3117-001) As per reference document ITR-1000-005 M W SW
11.4 Base coarse

(1) Base coarse Filling SLTR-S-000-3117-001 (S-000-3117-001) As per reference document ITR-1000-005 M W SW
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B. Job mix formal to be added, if any ( as per approved drawing )
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(2) Base coarse Compaction SLTR-S-000-3117-001 (S-000-3117-001) As per reference document ITR-1000-005 M W SW
11.5 Road Signage Marking

(1) Road Stop, Sign, Lattering Drawing As per Drawing M W SW
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ATTACHMENT-2
Site Inspection and Test Record (ITR) Form
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INSPECTION AND TEST RECORD (ITR) FORM
NO. ITR FORM NO. REVISION TABLE OF CONTENT SHEET
EARTH WORK
1 ITR-2000-01 C Pre-Concrete Inspection Report 1
2 ITR-2000-02 C Concrete Docket Inspection Report 2
3 ITR-2000-03 C Compression Test Inspection Report 3
4 ITR-2000-04 C Concrete Strength Inspection Report 4
5 ITR-2000-05 C Compaction Inspection Report 5
6 ITR-2000-06 C Paving Inspection Report 6
7 ITR-2000-07 C Excavation Inspection Report 7
8 ITR-2000-08 C Concrete Inspection Report 8
9 ITR-2000-09 C Backfilling Inspection Report 9
10 ITR-2000-10 C Grouting Works Inspection Report 10
11 ITR-2000-11 C Civil Release Notice Inspection Report 11
12 ITR-1000-01 C Sewer Piping and Wrapping Inspection Report 12
13 ITR-1000-04 C Material Receiving Inspection Report 13
14 ITR-1000-05 C Sub-base and Base Coarse Backfilling Inspection Report 14
15 ITR-1000-06 C Road Marking Inspection Report 15
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ITR-2000-001
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PRE-CONCRETING INSPECTION REPORT
Project Title : Sumbawa LNG Terminal & Regas Project
Job Code : 0-0831-00-0000
Company : PT. Medco Sumbawa Gas Date : MM/DD/YY
Contractor : PT. JGC Indonesia Report No. : (by subcontractor)
Sub-Contractor : Page : of
REFERENCES :
Drawing No. : Location :
Revision :
work Description :
Sheet :
APPROVAL
NO INSPECTION ITEMS REMARKS
(Sub-Con) JIND MSG
1 SURVEY
2 BASE COMPACTION
3 REBAR WORK :
a. SIZE / TYPE
b. SPACING
c. SPLICING
d. COVERS
4 FORMWORK:
a. DIMENSION
b. ALIGNMENT
c. TIGHTNESS
d. STRENGTH
e. FORM OIL
f. CLEANLINESS
5 CONSTRUCTION: CHIPPING
6 JOINT: CLEANLINESS
7 ANCHOR BOLTS:
a. TYPE
b. SIZE
c. PROJECTION
d. LOCATION
8 PLUMBNESS
9 ELEVATION
10 TOP OF LEAN CONCRETE
11 TOP OF CONCRETE
12 THICKNESS OF CONCRETE
13 OTHERS:
a. CHAMFER
b. EMBEDDED MATERIAL
c. COATING/SURFACE PROJECTION
d. WATER STOP
e. CLEANLINESS
Legend Supporting document attached

LS : Lime Stone
CLY : Clay Silt YES NO
SCLY : Sandy Clay
COMMENT
Prepared by, Witnessed/Reviewed by, Witnessed/Reviewed by,

(sub contractor name) PT. JGC INDONESIA PT. MEDCO SUMBAWA GAS
Print name Date Print name Date Print name Date
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ITR-2000-002
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DOCKET CONCRETE INSPECTION REPORT
Job Code : 0-0831-00-0000
REFERENCES :
Revision :
Sheet :
CONCRETE DOCKET DOC NO :

CONCRETE MIX TYPE ORDER NO :
DATE :
TRUCK NO: ORDERED QUANTITY : M3 TOTAL
QUANTITY: M3 / TRUCK
ACCUMULATIVE QTY M3
START MIXING TIME： HR
REMARK: BATCHING PLANT SUPERVISOR
0
SLUMP ： mm TEMP. OF CONCRETE： C
0
TEMP. OF AMBIENT： C
INSPECTED BY:
PC-WBS
LOCATION： ARRIVING TIME： HR
EQPT/STRUCT NO/： COMPLETED TIME： HR
STRUCTURE： □ BLINDING CONCRETE □ FOUNDATION □ COLUMN
□ WALL □ BEAM □ SLAB
PLACING METHOD □ PUMP □ CHUTE □ OTHERS
□ TREMIE □ BUCKET
ANY TEST CUBE IS MADE? YES □ NO NUMBER:
TEST CUBE NUMBER IF TAKEN:
SUBCONTRACTOR CONTRACTOR OWNER
NAME NAME NAME
DATE DATE DATE

LS : Lime Stone
SCLY : Sandy Clay
COMMENT

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ITR-2000-003
SUBCONT. Rev C
LOGO
COMPRESSION TEST INSPECTION REPORT
Job Code : 0-0831-00-0000
Sub-Contractor : Page : of To track the Doc
REFERENCES :
Revision : Cube ID and FIN
Sheet : NO
CONCRETE MIX TYPE

DATE OF CASTING :
VOLUME (Cu M) :
SLUMP (MM)
:
7 DAYS TEST DATE :

TEST SPECIMENS 1 2 3 AVERAGE
DIMENSION (MM)
LENGTH (MM)
CROSS-SECTIONAL AREA
2
(MM )
MAXIMUM LOAD (KN)
COMPRESSIVE STRENGTH
(Mpa)
SIGNATURE 3rd PARTY CONTRACTOR OWNER
SUBCONTRACTOR INSPECTOR
DATE : DATE : DATE : DATE :

NAME : NAME : NAME : NAME :
28 DAYS TEST DATE :

TEST SPECIMENS 1 2 3 AVERAGE
DIMENSION (MM)
LENGTH (MM)
CROSS-SECTIONAL AREA
2
(MM )
MAXIMUM LOAD (KN)
COMPRESSIVE STRENGTH
(Mpa)
rd
SIGNATURE 3 PARTY CONTRACTOR OWNER
SUBCONTRACTOR INSPECTOR
DATE : DATE : DATE : DATE :

NAME : NAME : NAME : NAME :

LS : Lime Stone
SCLY : Sandy Clay
COMMENT

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ITR-2000-004
SUBCONT. Rev C
LOGO
CONCRETE STRENGTH INSPECTION REPORT
Job Code : 0-0831-00-0000
REFERENCES :
Revision :
Sheet :
REC. DATE TIME LOCATION DWG SLUMP STRENGTH REMARKS

NO. Y/N 7 DAYS 28 DAYS

LS : Lime Stone
SCLY : Sandy Clay
COMMENT

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ITR-2000-005
SUBCONT. Rev C
LOGO
COMPACTION INSPECTION REPORT
Job Code : 0-0831-00-0000
REFERENCES :
Revision :
Sheet :
Pls add the ITR for

core cutting method,
sand replacement
and nuclear density
gauge method for
compaction

LS : Lime Stone
SCLY : Sandy Clay
COMMENT

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ITR-2000-006
SUBCONT. Rev C
LOGO
PAVING INSPECTION REPORT
Job Code : 0-0831-00-0000
REFERENCES :
Revision :
Sheet :
APPROVAL
(Sub-Con) JIND MSG
1 SURVEY AND LAYOUT
2 BASE COMPACTION
3 POLYETHENE SHEET OVERLAP
4 REINFORCING MESH
a. SIZE
b. SPLICING
5 REBARWORK
a. SIZE
b. SPACING (IF APPLICABLE)
c. SPLICING
d. COVER
6 CONSTRUCTION JOINT
a. SPACING
b. CRACK IND.
c. JOINT FILLER
7 CLEANLINESS

LS : Lime Stone
SCLY : Sandy Clay
COMMENT

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ITR-2000-007
SUBCONT. Rev C
LOGO
EXCAVATION INSPECTION REPORT

Job Code : 0-0831-00-0000
REFERENCES :
Revision :
Sheet :
APPROVAL
(Sub-Con) JIND MSG
1 Setting out survey before excavation
2 Finishing survey
3 Excavation survey

LS : Lime Stone
SCLY : Sandy Clay
COMMENT

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ITR-2000-008
SUBCONT. Rev C
LOGO
CONCRETE INSPECTION REPORT

Job Code : 0-0831-00-0000
REFERENCES :
Revision :
Sheet :
APPROVAL
(Sub-Con) JIND MSG
1 Concrete Curing Properly Done
2 Concrete Surface Check and Patch Up Repair
3 Concrete Coating
4 Approved Materials for Concrete Repair
5 Approved Materials for Concrete Coating

LS : Lime Stone
SCLY : Sandy Clay
COMMENT

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ITR-2000-009
SUBCONT. Rev C
LOGO
BACKFILLING INSPECTION REPORT

Job Code : 0-0831-00-0000
REFERENCES :
Revision :
Sheet :
APPROVAL
(Sub-Con) JIND MSG
1 Approved Backfill Materials
2 Foreign Materials Removed
3 Backfill layer Thickness/Compaction
4 Compaction for Clean Sand
5 Compaction for Marl Mixed Materials
6 Compaction Test (Density) Result
7 Level Survey After Backfilling/Compaction
8 Surface Conditions
9 Previous Layer Field Density Result

LS : Lime Stone
SCLY : Sandy Clay
COMMENT

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ITR-2000-010
SUBCONT. Rev C
LOGO
GROUTING WORKS INSPECTION REPORT

Job Code : 0-0831-00-0000
REFERENCES :
Revision :
Sheet :
APPROVAL
(Sub-Con) JIND MSG
1 Release for Grouting (Mech., Elec.)
2 Approved of Grout Materials
3 Type of Grout (Non-Shrink Epoxy)
4 Concrete Surface Preparation
- Shim Plate Elevation
- Chipping Anchor Bolts Protection, etc.
- Ambient Temperature
- Foundation Temperature
5 Fromwork, Chamfer, Soaking
6 Grout Mixing and Placing
- Mixing Ratio
- Grout Temperature After Mixing
- Cube Test Sample Taken
7 Grout Curing
8 Grouting Acceptance
- Cube Test Result
- Final Inspection, Bonding Test, etc.
- Finishing, no Cracks as per ACI 224R

Chapter 4.4 etc.

LS : Lime Stone
SCLY : Sandy Clay
COMMENT

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ITR-2000-011
SUBCONT. Rev C
LOGO
CIVIL RELEASE NOTICE INSPECTION REPORT
Job Code : 0-0831-00-0000
REFERENCES :
Revision :
Sheet :

LS : Lime Stone
SCLY : Sandy Clay
COMMENT

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ITR-1000-001
SUBCONT. Rev C
LOGO
SEWER PIPING AND WRAPPING INSPECTION REPORT
Job Code : 0-0831-00-0000
REFERENCES :
Revision :
Sheet :
INSPECTION REPORT FOR SEWER PIPING

＆ WRAPPING FORM NO. : 1000-001
DOC NO.:
DSLNG Project REPORT NO. :
0-5151-20
LOCATION : -
ISO DWG No.:
PIT NO: TO
TYPE OF PIPE RCP PIPE CS PIPE
SIZE OF PIPE ∳ ∳
PIPE LENGTH M
CHECK POINT : ELEVATION CENTER LINE BEDDING

DURING PIPE
INSTALLATION SUPPORT DEWATERING
INSPECTED BY BY
SUBCONTRACTOR CONTRACTOR
JOINTING : JOINT SURFACE KEY JOINT/ IF WELD JOINT & PAINTING
ADHESIVE JOINT ATTACH REPORT:
DATE OF INSPECT INSPECTED BY: SUBCONT’R
CONTRACTOR
WRAPPING SURFACE PREPA’N

OVERWRAPPING
APPERENCE VOLTAGE ________
HOLIDAY TEST mV
INSPECTED BY: SUBCONT’R
DATE INSPECTION INSPECTED BY:
STRUCTURAL FILL COMPACTION RESULT CONTRACTOR
BACKFILLING COMPACTION TEST
%
INSPECTED BY: SUBCONT’R

DATE OF INSPECTION INSPECTED BY:
WATER FILLING TEST FROM TO WATER DROP MM

FOR PIPES
INSPECTED BY
WATER FILLING TEST FROM TO WATER DROP MM
FOR PIT
INSPECTED BY
Performed by Witnessed / Reviewed Witnessed / Reviewed
Date: Date: Date:

LS : Lime Stone
SCLY : Sandy Clay
COMMENT

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ITR-1000-004
SUBCONT. Rev C
LOGO
MATERIAL RECEIVING INSPECTION REPORT

Job Code : 0-0831-00-0000
REFERENCES :
Revision :
Sheet :
Dimensional Visual
Item PO Number Description Unit Qty Tag No Certificate No
Acc Rej Acc Rej
COMMENT

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ITR-1000-005
SUBCONT. Rev C
LOGO
SUB BASE AND BASE COARSE BACKFILLING INSPECTION REPORT

Job Code : 0-0831-00-0000
REFERENCES :
Revision :
Sheet :
APPROVAL
(Sub-Con) JIND MSG
1 Approved Backfill Materials for Sub-base coarse
3 Sub-base coarse Backfill layer Thickness
4 Sub-base coarse Compaction Test Result
Sub-base coarse Level Survey After

5
Backfilling/Compaction
6 Sub-base coarse Surface Conditions
7 Approved Backfill Materials for Base coarse
9 Base coarse Backfill layer Thickness
10 Base coarse Compaction Test Result

Base coarse Level Survey After
11
12 Base coarse Surface Conditions

LS : Lime Stone
SCLY : Sandy Clay
COMMENT

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NCON
ITR-1000-005
SUBCONT. Rev C
LOGO
ROAD MARKING INSPECTION REPORT

Job Code : 0-0831-00-0000
REFERENCES :
Revision :
Sheet :
APPROVAL
(Sub-Con) JIND MSG
1 Approved Backfill Materials for Sub-base coarse
2 Foreign Materials Removed Title and inspection items is not

meeting
3 Sub-base coarse Backfill layer Thickness
4 Sub-base coarse Compaction Test Result
Sub-base coarse Level Survey After

5
6 Sub-base coarse Surface Conditions
7 Approved Backfill Materials for Base coarse
9 Base coarse Backfill layer Thickness
10 Base coarse Compaction Test Result

Base coarse Level Survey After
11
12 Base coarse Surface Conditions

LS : Lime Stone
SCLY : Sandy Clay
COMMENT

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NCON

S-000-1310-101-Rs-00077 Site Inspection and Test Plan (Itp) For Civil Work

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S-000-1310-101-Rs-00077 Site Inspection and Test Plan (Itp) For Civil Work

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COMPANY DOCUMENT NO.

JOB CODE REV.

SUMBAWA LNG TERMINAL &

SITE INSPECTION AND TEST PLAN (ITP)

REV. DATE PAGE DESCRIPTION PREP’D CHK’D APP’D CPY APP’D

1A 18-Jan-23 All Issued for Review R. Setiawan Anthonius F.T Subekti

2. PURPOSE AND SCOPE

3. DEFINITION AND ABBREVIATION

6. INSPECTION INTERVENTION LEVEL

Letter Abbreviation Description

CONTRACTOR/COMPANY intends to conduct witness

CONTRACTOR/COMPANY intends to conduct witness

CONTRACTOR/COMPANY intends to conduct witness

Preparation and execution of measurement, observation,

SUBCONTRACTOR is requested to submit the documents or

(2) Site Inspection and Test Record (ITR) Form

SITE INSPECTION AND TEST PLAN (ITP) FOR CIVIL WORKS

1 EARTH WORK (Include Road and Paving)

(2) Finishing survey As per each drawing ITR-2000-007 M W R -

(3) Tolerance ITR-2000-007

(3.1) Excavation tolerance SLTR-S-000-3115-001 As per applicable specification M W R -

(3.2) Graveled area SLTR-S-000-3117-001 As per applicable specification M W R -

1.2 Fill Material

(2) Base material for road SLTR-S-000-3117-001 As per applicable specification M W R -

1.3 Filling and Compaction

Thickness/per layer Max. 300 mm ITR-2000-009

SITE INSPECTION AND TEST PLAN (ITP) FOR CIVIL WORKS

INSPECTION INTERVENTION LEVEL

(3.1) Filling SLTR-S-000-3115-001 As per applicable specification ITR-2000-009 M W R -

(3.2) Graveled area SLTR-S-000-3117-001 As per applicable specification M W R -

2.1.1 Material approval

Cement remaining in weather-tight

(4) Admixture or additve Section 6.4 Manufacturer certificate/MSDS M R R - Every Delivery

(5) Reinforcing bar Manufacture’s certificate Manufacture’s certificate M R R -

SITE INSPECTION AND TEST PLAN (ITP) FOR CIVIL WORKS

INSPECTION INTERVENTION LEVEL

- Deform rebar SNI-07-2052-2002 Grade BJTS40,

(7) Embedded Steel Applicable drawing, mill certificate M SW R -

(8) Water Stop Manufacture's certificate M SW R -

(1.1) Slump test SLTR-S-000-3120-001 M W SW -

(1.2) Air contents ASTM C138, C173 or C231 M R R -

(1.3) Temperature Max. 38 deg. C M W SW -

(1.4) Compression Test One at 7 days for information, Three ITR-2000-003 M W SW -

(1.1) Slump test SLTR-S-000-3120-001 M W SW -

(3) SO3 content Max. 4% by cement wt. -

(4) Temperature Max. 38 deg. C -

(5) Compression test One at 7 days for information, Three ITR-2000-003 M W SW -

Concrete design mix detail to be

SITE INSPECTION AND TEST PLAN (ITP) FOR CIVIL WORKS

INSPECTION INTERVENTION LEVEL

2.3 Concrete Foundation

(1) Blinding concrete ITR-2000-001 -

(1.1) Ground condition Clear of loose material M W R -

(1.2) Check of level/Location As per drawing M W R -

(1.3) Thickness Minimum 50 mm M W R -

(2) Re-bar work SLTR-S-000-3120-001 ITR-2000-001 -

(2.1) Bar size / Type Drawing M W SW -

(2.2) Number of bar Drawing M W SW -

(2.3) Length Drawing M W SW -

(2.4) Condition of re-bar ACI 117 As per section 8.2.3 M W SW -

(2.5) Splicing ACI 117 Drawing M W SW -

(2.6) Spacing ACI 117 As per drawing M W SW -

(2.7) Hook ACI 117 As per drawing M W SW -