Elawad Hassan

2.4.2019



PROVISION OF EPCC FOR WATER INJECTION BOOSTING
STATION BOOSTING UPGRADE CIVIL
INSPECTION AND TEST PLAN


CONTENTS
1.0 Earth Work ------------------------------------------------------------------ 2
2.0 Concrete Work -------------------------------------------------------------- 5
3.0 Fence and gate--------------------------------------------------------------- 11
4.0 Grouting---------------------------------------------------------------------- 14

ATTACHMENT:

HFY3-3-1-1 Inspection checklist Earthwork Excavation… ………. ..…15

HFY3-3-1-2 Inspection checklist Earthwork Backfilling………….....…….17
HFY3-3-2-1 Inspection checklist formwork &reinforcing steel………..…...19
HFY3-3-2-2 Inspection checklist concrete pouring………………………..20
HFY3-3-2-3 Inspection checklist anchor bolt& embedded items…………22
HFY3-3-7 Inspection checklist fence &gate……………….…...……23
HFY3-003-9 Inspection’s daily report grouting works………....…....…….24

HFY3-3-5-3 Inspection checklist Doors and windows……………….…...26

HFY3-3-5-4 Inspection checklist Roof water proofing……………….…...27

HFY3-3-5-5 Inspection checklist painting and decoration………………...29

CL-C-01 Checklist of foundation coating…………………...………..…31

CR-C-01 Level Record……………………………….………….……..32
CR-C-02 Coordinate Record…………………………….…….....…….33
CR-C-03 Excavation Record……………………………….….…..…...34
CR-C-04 Foundation Survey Record……………………….……...…..35
CR-C-05 Material Inspection Record……………………….…..……...36
 PROVISION OF EPCC FOR WATER INJECTION STATION
BOOSTING UPGRADE CIVIL INSPECTION AND TEST

CPECC WATER INJECTION BOOSTING STATION UPGRADE

DISCIPLINE:CIVIL DESCRIPTION OF WORK : CIVIL WORK SITE INSPECTION & TEST PLAN HFY3-3720-CIV-ITP-0001

COMMENTS DEFINITION OF INSPECTION AND TEST PLAN SYMBOLS APPLICABLE TO ALL SIGNATORIES

S-CON = Sub-Contractor
CPECC = China Petroleum Engineering Construction Corporation
PMC: Project Management Consultant

“H” - HOLD: A point beyond which work shall not proceed without formal approval by the appropriate inspection. Contractor shall
notify the COMPANY / PMC and raise RFI.

“W” - WITNESS: A point beyond which work may proceed without formal documented approval by any of the inspection.
Achievement of “W” points shall be notified to PMC in accordance with the contract.

"S" - SURVEILLANCE: A point where CPECC and others may carry out surveillance of work in progress and documentation associated on
an unscheduled basis, with no notification required by any party and without amendment to the scheduled
production program.

“R” - REVIEW: The documents are to be submitted to the appropriate inspection for review by PMC. Note that where a document is
subject to CPECC/PMC approval, work shall not proceed until CPECC/PMC approval is given.

REMARKS:

1
 PROVISION OF EPCC FOR WATER INJECTION STATION
BOOSTING UPGRADE CIVIL INSPECTION AND TEST

CPECC WATER INJECTION BOOSTING STATION UPGRADE

SITE INSPECTION
DISCIPLINE:CIVIL DESCRIPTION OF WORK: EARTH WORKS HFY3-3720-CIV-ITP-0001
& TEST PLAN
Date: Prepared By: CPECC QC DEPARTMENT Approved By: CPECC QC DEPARTMENT
Item Inspection Activity and Specific Acceptance Criteria, Verifying RESPONSIBILITY
ACTIVITY
No. Check Point Area Code & Standard Document CONTRACTOR PMC
1 Earth works
1.1 All drawings shall conform to Construction drawings
Construction procedures W R
latest approved edition. of civil engineering

1.2 All backfilling materials shall

conform to design drawings. Any Construction drawings HFY-Checklist-3-1-1 H R
backfilling materials which are Construction procedures HFY-Checklist-3-1-2
unsuitable shall be individually piled. of civil engineering CR-C-01
CR-C-02
CR-C-03
1.3 All excavation shall be performed CR-C-04
either by machines or by hand in a Construction drawings CR-C-05
Construction procedures H S
safe manner. Final excavation shall be of civil engineering
done by hand.

1.4 Materials, such as deleterious

material, trees, roots and vegetations Construction drawings W S
etc. that are not suitable for backfilling, Construction procedures
shall be removed from site and of civil engineering
delivered to the designated area.

Definitions of Inspection & Test plan Symbols: H -Hold W -Witness Point S –Surveillance R –Review

2
 PROVISION OF EPCC FOR WATER INJECTION STATION
BOOSTING UPGRADE CIVIL INSPECTION AND TEST

CPECC WATER INJECTION BOOSTING STATION UPGRADE

SITE INSPECTION
DISCIPLINE: CIVIL DESCRIPTION OF WORK: EARTH WORKS HFY3-3720-CIV-ITP-0001
& TEST PLAN
Date: Prepared By: CPECC QC DEPARTMENT Approved By: CPECC QC DEPARTMENT

Item Inspection Activity and Specific Acceptance Criteria, Verifying RESPONSIBILITY

ACTIVITY
No. Check Point Area Code & Standard Document CONTRACTOR PMC
1.5 Filling material shall be of optimum Construction drawings H W
water content and shall be Construction procedures
of civil engineering
compacted in layers. After that,
field density tests shall be
performed.
HFY-Checklist-3-1-1
Construction drawings HFY-Checklist-3-1-2
1.6 OMC, MDD & Sieve Analysis for Construction procedures CR-C-01 H R
the soil to be backfilled. of civil engineering CR-C-02
CR-C-03
CR-C-04
CR-C-05
1.7 Foundation shall be compacted. Any Construction drawings
places where are over-excavated shall Construction procedures
be backfilled to designed level and of civil engineering H W
compacted accordingly.

Definitions of Inspection & Test plan Symbols: H -Hold W -Witness Point S -Surveillance R –Review

3
 PROVISION OF EPCC FOR WATER INJECTION STATION
BOOSTING UPGRADE CIVIL INSPECTION AND TEST

CPECC WATER INJECTION BOOSTING STATION UPGRADE

SITE INSPECTION
DISCIPLINE:CIVIL DESCRIPTION OF WORK: EARTH WORKS HFY3-3720-CIV-ITP-0001
& TEST PLAN

Date: Prepared By: CPECC QC DEPARTMENT Approved By: CPECC QC DEPARTMENT

Item Inspection Activity and Specific Acceptance Criteria, Verifying RESPONSIBILITY
ACTIVITY
No. Check Point Area Code & Standard Document CONTRACTOR PMC
1.8 While excavation is being done, Construction drawings W S
care shall be exercised to avoid Construction procedures
of civil engineering
damaging existing underground
utilities.

1.9 Excavation shall be done with Construction drawings W S

Construction procedures
sufficient working space. HFY-Checklist-3-1-1
of civil engineering
HFY-Checklist-3-1-2
1.10 Chances of movement of CR-C-01
required material within site shall be CR-C-02
reduced. Safety operation on Construction drawings CR-C-03 W S
Construction procedures
excavation site shall be ensured. CR-C-04
of civil engineering
Do not pile too much excavated CR-C-05
material on both sides of pipe trench
so as to avoid over loading.

1.11 Materials that can not be used

Construction drawings
shall be delivered to the designated Construction procedures W S
area. of civil engineering

Definitions of Inspection & Test plan Symbols: H -Hold W -Witness Point S -Surveillance R –Review

4
 PROVISION OF EPCC FOR WATER INJECTION STATION
BOOSTING UPGRADE CIVIL INSPECTION AND TEST

CPECC WATER INJECTION BOOSTING STATION UPGRADE

SITE INSPECTION
DISCIPLINE:CIVIL DESCRIPTION OF WORK: CONCRETE WORKS HFY3-3720-CIV-ITP-0001
& TEST PLAN
Date: Prepared By: CPECC QC DEPARTMENT Approved By: CPECC QC DEPARTMENT
Item Inspection Activity and Specific Acceptance Criteria, Verifying RESPONSIBILITY
ACTIVITY
No. Check Point Area Code & Standard Document CONTRACTOR PMC
2 2 concrete 2.1.1 Batch Plant Qualification & Construction drawings
work Trial Mix Design( For each Concrete Construction procedures H R
of civil engineering
Grad)

2.1concrete Construction drawings H W

material and 2.1.2 Blinding Concrete and Water Construction procedures
of civil engineering HFY-Checklist-3-2-1
mixing design Proofing material shall conform to
approved drawing and specifications. HFY-Checklist-3-2-2
CR-C-05
Construction drawings H W
2.2.1 Spacers, clean, align and level Construction procedures
2.2formwork formwork edges shall conform latest of civil engineering
edition of approved drawings.

Construction drawings
2.2.2 Materials should be approved Construction procedures W S
and are in good conditions. of civil engineering

Definitions of Inspection & Test plan Symbols: H -Hold W -Witness Point S -Surveillance R –Review

5
 PROVISION OF EPCC FOR WATER INJECTION STATION
BOOSTING UPGRADE CIVIL INSPECTION AND TEST

CPECC WATER INJECTION BOOSTING STATION UPGRADE

SITE INSPECTION
DISCIPLINE:CIVIL DESCRIPTION OF WORK: CONCRETE WORKS HFY3-3720-CIV-ITP-0001
& TEST PLAN
Date: Prepared By: CPECC QC DEPARTMENT Approved By: CPECC QC DEPARTMENT
Item Inspection Activity and Specific Acceptance Criteria, Verifying RESPONSIBILITY
ACTIVITY
No. Check Point Area Code & Standard Document CONTRACTOR PMC
2.2.3 Reinforcement concrete cover Construction drawings
shall conform to approved drawings Construction procedures W W
of civil engineering
and specifications.

2.2.4 Contact surface between form- Construction drawings W S

Construction procedures HFY-Checklist-3-2-1
work and concrete shall be smooth
of civil engineering HFY-Checklist-3-2-2
without any deficiencies or
CR-C-05
unevenness.

W S
2.2.5 Clean-out shall be available on Construction drawings
Construction procedures
form-work. of civil engineering

2.2.6 Formwork shall be firmly Construction drawings H W

supported and movement of form Construction procedures
of civil engineering
work shall be avoided while casting
concrete.
Definitions of Inspection & Test plan Symbols: H -Hold W -Witness Point S -Surveillance R –Review

6
 PROVISION OF EPCC FOR WATER INJECTION STATION
BOOSTING UPGRADE CIVIL INSPECTION AND TEST

CPECC WATER INJECTION BOOSTING STATION UPGRADE

SITE INSPECTION
DISCIPLINE:CIVIL DESCRIPTION OF WORK: CONCRETE WORKS HFY3-3720-CIV-ITP-0001
& TEST PLAN
Date: Prepared By: CPECC QC DEPARTMENT Approved By: CPECC QC DEPARTMENT
Item Inspection Activity and Specific Acceptance Criteria, Verifying RESPONSIBILITY
ACTIVITY
No. Check Point Area Code & Standard Document CONTRACTOR PMC
2.2.7 Release agent used for form Construction drawings W S
work shall conform to design Construction procedures
of civil engineering
requirements.

2.2.8 Debris shall be removed from Construction drawings W S

forms. Construction procedures
of civil engineering
2.3 Steel bar 2.3.1 Steel bars provided by supplier Construction drawings HFY-Checklist-3-2-1
construction shall conform to the requirements of Construction procedures HFY-Checklist-3-2-2 H W
design drawings. of civil engineering CR-C-05

2.3.2 Steel bar shall have correct size,

Construction drawings
shape, spacers and bent radius Construction procedures H W
conforming to design requirements. of civil engineering

2.3.3 Steel bar installation shall be Construction drawings

according to approved design Construction procedures H W
drawings and shall be firmly tied. of civil engineering
Steel bar shall be supported in an
approved way.

Definitions of Inspection & Test plan Symbols: H -Hold W -Witness Point S -Surveillance R –Review

7
 PROVISION OF EPCC FOR WATER INJECTION STATION
BOOSTING UPGRADE CIVIL INSPECTION AND TEST

CPECC WATER INJECTION BOOSTING STATION UPGRADE

SITE INSPECTION
DISCIPLINE:CIVIL DESCRIPTION OF WORK: CONCRETE WORKS HFY3-3720-CIV-ITP-0001
& TEST PLAN
Date: Prepared By: CPECC QC DEPARTMENT Approved By: CPECC QC DEPARTMENT

Item Inspection Activity and Specific Acceptance Criteria, Verifying RESPONSIBILITY

ACTIVITY
No. Check Point Area Code & Standard Document CONTRACTOR PMC
2.3.4 All embedded items shall Construction drawings H W
conform to the requirements of design Construction procedures
of civil engineering
drawings, and shall be checked and
approved.

HFY-Checklist-3-2-1
2.4.1 Concrete grade and Slump, Construction drawings H W
2.4 Concrete temperature & vibration
Construction procedures
shall of civil engineering HFY-Checklist-3-2-2
Pouring and conform the approved drawing and HFY-Checklist-3-2-3
CR-C-05
Cube Casting specification.

2.4.2 The size, elevation & Construction drawings

coordinates of Anchor Bolts & Construction procedures
Embedded items installation shall of civil engineering H W
conform the drawing and
specification.

Definitions of Inspection & Test plan Symbols: H -Hold W -Witness Point S -Surveillance R –Review

8
 PROVISION OF EPCC FOR WATER INJECTION STATION
BOOSTING UPGRADE CIVIL INSPECTION AND TEST

CPECC WATER INJECTION BOOSTING STATION UPGRADE

SITE INSPECTION
DISCIPLINE:CIVIL DESCRIPTION OF WORK: CONCRETE WORKS HFY3-3720-CIV-ITP-0001
& TEST PLAN
Date: Prepared By: CPECC QC DEPARTMENT Approved By: CPECC QC DEPARTMENT

Item Inspection Activity and Specific Acceptance Criteria, Verifying RESPONSIBILITY

ACTIVITY
No. Check Point Area Code & Standard Document CONTRACTOR PMC
2.4.3 During concrete pouring, Construction drawings H W
concrete cube specimens should be Construction procedures
of civil engineering
prepared on site.

2.4.4 To complete the preparation of Construction drawings

HFY-Checklist-3-2-1
specimens and tests, compressive Construction procedures W S
strength shall be tested with cube
of civil engineering HFY-Checklist-3-2-2
specimens.

2.4.5 It is not allow to adding water Construction drawings

Construction procedures
to concrete to change its slump on of civil engineering
W W
site.

2.4.6 Concrete shall be placed with Construction drawings

Construction procedures
proper equipment and pouring heights of civil engineering
W W
shall be according to specified
requirements.
Definitions of Inspection & Test plan Symbols: H -Hold W -Witness Point S –Surveillance R –Review

9
 PROVISION OF EPCC FOR WATER INJECTION STATION
BOOSTING UPGRADE CIVIL INSPECTION AND TEST

CPECC WATER INJECTION BOOSTING STATION UPGRADE

SITE INSPECTION
DISCIPLINE:CIVIL DESCRIPTION OF WORK: CONCRETE WORKS HFY3-3720-CIV-ITP-0001
& TEST PLAN
Date: Prepared By: CPECC QC DEPARTMENT Approved By: CPECC QC DEPARTMENT

Item Inspection Activity and Specific Acceptance Criteria, Verifying RESPONSIBILITY

ACTIVITY
No. Check Point Area Code & Standard Document CONTRACTOR PMC
2.4.7 Concrete vibration shall be Construction drawings W S
performed in accordance with Construction procedures
of civil engineering
construction specification and design
requirements.

2.4.8 Concrete shall be cured with Construction drawings W S

Construction procedures HFY-Checklist-3-2-1
methods required by contract. curing of civil engineering
HFY-Checklist-3-2-2
for 7 days.
CL-C-01

Construction drawings
2.5 2.5.1 Underground part of concrete Construction procedures H S
Foundation shall be painted bitumen anticorrosion of civil engineering
Coating layer.

Definitions of Inspection & Test plan Symbols: H -Hold W -Witness Point S -Surveillance R –Review

10
 PROVISION OF EPCC FOR WATER INJECTION STATION
BOOSTING UPGRADE CIVIL INSPECTION AND TEST

CPECC WATER INJECTION BOOSTING STATION UPGRADE

SITE INSPECTION
DISCIPLINE:CIVIL DESCRIPTION OF WORK: FENCE AND GATE HFY3-3720-CIV-ITP-0001
& TEST PLAN
Date: Prepared By: CPECC QC DEPARTMENT Approved By: CPECC QC DEPARTMENT

Item Inspection Activity and Specific Acceptance Criteria, Verifying RESPONSIBILITY

ACTIVITY
No. Check Point Area Code & Standard Document CONTRACTOR PMC
3 fence and gate 3.1.1 All material for fence and Construction drawings W W
3 3.1Material gate shall be according to design Construction procedures
of civil engineering
requirements.

W S
Construction drawings
3.1.2 Surface which metallic Construction procedures HFY-Checklist-3-7
members are in contact with soil of civil engineering CR-C-05
shall be corrosion protective.

Construction drawings
3.2Construction 3.2.1 Construction drawings shall be Construction procedures W S
the latest approved edition. of civil engineering

Definitions of Inspection & Test plan Symbols: H –Hold W –Witness Point S –Surveillance R –Review

11
 PROVISION OF EPCC FOR WATER INJECTION STATION
BOOSTING UPGRADE CIVIL INSPECTION AND TEST

CPECC WATER INJECTION BOOSTING STATION UPGRADE

SITE INSPECTION
DISCIPLINE:CIVIL DESCRIPTION OF WORK: FENCE AND GATE HFY3-3720-CIV-ITP-0001
& TEST PLAN
Date: Prepared By: CPECC QC DEPARTMENT Approved By: CPECC QC DEPARTMENT

Item Inspection Activity and Specific Acceptance Criteria, Verifying RESPONSIBILITY

ACTIVITY
No. Check Point Area Code & Standard Document CONTRACTOR PMC
3.2.2 Post Installation with Construction drawings W S
Concrete Foundation as per design Construction procedures
of civil engineering
drawing.

3.2.3 Chain link fencing. Construction drawings W S

A)Tension wires shall be correctly Construction procedures
of civil engineering
installed and properly tightened. HFY-Checklist-3-7
B)Wire mesh for chain-link fencing
shall be properly tensioned and shall CR-C-05
be of correct height.

Construction drawings
3.2.4 Installation of Barbed Construction procedures W S
Wire, Razor Wire & Top Rail of civil engineering
shall conform the design drawing
and specification.

Definitions of Inspection & Test plan Symbols: H –Hold W –Witness Point S –Surveillance R –Review

12
 PROVISION OF EPCC FOR WATER INJECTION STATION
BOOSTING UPGRADE CIVIL INSPECTION AND TEST

CPECC WATER INJECTION BOOSTING STATION UPGRADE

SITE INSPECTION
DISCIPLINE:CIVIL DESCRIPTION OF WORK: FENCE AND GATE HFY3-3720-CIV-ITP-0001
& TEST PLAN
Date: Prepared By: CPECC QC DEPARTMENT Approved By: CPECC QC DEPARTMENT

Item Inspection Activity and Specific Acceptance Criteria, Verifying RESPONSIBILITY

ACTIVITY
No. Check Point Area Code & Standard Document CONTRACTOR PMC
3.2.5 Blast Cleaning, Painting & Construction drawings W S
Installation of Gate shall conform to Construction procedures
of civil engineering
design requirements.

3.2.6 Galvanized corrugated plate

fencing Construction drawings
Construction procedures
of civil engineering
a) Posts erection shall conform to HFY-Checklist-3-7
design requirements. CR-C-05 W S

b) Corrugated plate shall be securely

fixed to the posts in plumb and level.
A certain space shall be required
between bottom of plate and ground.

Construction drawings
3.2.7 Final walk down should Construction procedures
W S
be performed. of civil engineering

Definitions of Inspection & Test plan Symbols: H -Hold W -Witness Point S -Surveillance R –Review

13
 PROVISION OF EPCC FOR WATER INJECTION STATION
BOOSTING UPGRADE CIVIL INSPECTION AND TEST

CPECC WATER INJECTION BOOSTING STATION UPGRADE

SITE
DISCIPLINE:CIVIL DESCRIPTION OF WORK: GROUTING INSPECTION & HFY3-3720-CIV-ITP-0001
TEST PLAN
Date: Prepared By: CPECC QC DEPARTMENT Approved By: CPECC QC DEPARTMENT
Item Inspection Activity and Specific Acceptance Criteria, Verifying RESPONSIBILITY
ACTIVITY
No. Check Point Area Code & Standard Document CONTRACTOR PMC
4.1 Ensure the material for grouting as per W R
the project specification and approved by
the OWNER. Material certificate attached.
4.2 Ensure the Formwork (water-tight) for W W
grouting is in good condition as
requirement.
4.3 Ensure the equipment/anchor bolts is R
installed as per the approved drawings, and W
4 4 Grouting accepted by QC and the OWNER/PMC HFY-Checklist-003-9
before grouting. Construction drawings CR-C-05
4.4 Ensure the area/pockets for grouting is Construction procedures
clean and fully wet for cement grouting of civil engineering W R
material without any foreign materials. The
surface is prepared as per the specification
as applicable.
4.5 Ensure the grouting is mixed and W R
placed as per the vendor recommendation
and specification.
4.6 Ensure a good curing is maintained. W R
4.7 Cube Casting & Curing
Cube Crushing for 7 days & 28 days. W R
Definitions of Inspection & Test plan Symbols: H -Hold W -Witness Point S -Surveillance R –Review

14
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6 Concrete mus t be del i vered a nd poured from the truck mi xer or a gi ta tor truck concrete?
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7 Concrete mus t be poured wi th proper equi pment a nd pouri ng hei ght s ha l l not පK<පEŽƚK<
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……………………………………………………
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 Check List of Foundation Coating
CL-C-01

Project No: Record No.:

Job Name: Location:
Drawing No.: Date:
ITEM ACTIVITY YES NO
Before the construction, the first grass on the surface of the
1 gray skin with a knife to remove, with a broom to dust, sand
and other debris clean.
If oil, apply wire brush and sandpaper to brush off.
2 The base surface must be flat, the depression should be filled
with cement putty.
When painted bitumen, the temperature of concrete surface
3 should be satisfy vendor request.
Anti-coating without a drum, cracking, Alice and other
4 defects.
REMARKS:

Contractor PMC Engineer

Name
Signature
Date

31
 Level Record
CR-C-01
Drawing No. Record No.
Project Work Area
Control Point No. Control Point Elevation
Elevation ±0.000 Survey Instrument
Date Climate sunny
Backsight Foresight Elevation Backsight Foresight Elevation
No. Remark No. Remark
mm mm m mm mm m
1
2
3
4
5
6
7
8
SKETCH

Engineer QC Engineer PMC Engineer

Name

Signature

Date

32
 Coordinate Record
CR-C-02

Project Record No.

Subject Work Area
Control Point East (m) North(m) Constructor
Survey
Instrument
Date
Climate
Drawing Number

North Azimuth
Point No. East (m) Distance (m) Remarks
(m) o ` "
SKETCH

Engineer QC Engineer PMC Engineer

Name
Signature
Date

33
 PROVISION OF EPCC FOR WATER INJECTION BOOSTING STATION
UPGRADE CIVIL INSPECTION AND TEST PLAN

Trench Excavation Record

CR-C-03
Project Record No.
Trench Parameter Trench Parameter
Point No. Point No.
Depth (m) Width (m) Distance From Start Point Depth (m) Width (m) Distance From Start Point

Remarks:

Engineer QC Engineer PMC Engineer

Name
Signature
Date

34
 PROVISION OF EPCC FOR WATER INJECTION BOOSTING STATION
UPGRADE CIVIL INSPECTION AND TEST PLAN

Foundation Survey Record

CR-C-04

Project Record No.

Subdivision Works
Drawing No.: Work Area: Name:
Controlling Point Controlling Point
Elevation ±0.00 :
Stake No.: Elevation:
Survey Electronic total Actual
instrument Climate:
Instrument: Leveling instrument surveying date:
Designed Actual Coordinate Elevation REMARK
Coordinate Stiff
Coordinate Difference Difference
(concrete plate
(concrete center) (mm) Designed Measured (mm)
Ite Surveying
Point No. Elevation Elevation Yes/No
ms
(m) (m)
N E N E + ˉ
ᶭN ᶭE

Engineer QC Engineer PMC Engineer

Name

Signature

Date

34
3 4
 PROVISION OF EPCC FOR WATER INJECTION BOOSTING STATION
UPGRADE CIVIL INSPECTION AND TEST PLAN

Material Inspection Record CR-C-05

Project Record No.
Material Grade/ Mill Test Inspection Result
Item Material Description Pages MFG No.
Manufacturer Certificate No Dimension Quantity Physical Accept Reject Hold

Remarks:

Engineer QC Engineer PMC Engineer

Name
Signature
Date

34
3 4