Formulir

RENCANA PENGAMBILAN CONTOH

(SAMPLING PLAN)
007 / ST-OD/ IGS / 10 / 2023

1. Komoditi (Commodity) : mainan anak

2. No & Judul SNI (SNI No & Title) : …………………………………………………………………………….
3. Sistem Sertifikasi (Certification System) : 1N………………….
4. Nama Perusahaan Pemohon (Company) : ……PT IGS………………………………..
5. Alamat Perusahaan Pemohon (Company Address) : SERPONG…………………………………………………………………………….
…………………………………………………………………………….
6. Alamat Pabrik (Factory Address) : CHINA…………………………………………………………………………….
…………………………………………………………………………….
7. Lokasi Pengambilan Contoh (Sampling Location) : CHINA…………………………………………………………………………….
…………………………………………………………………………….
8. Tanggal Pengambilan Contoh (Date of Sampling) : 20/10/2023……………………………………..
9. Kondisi Contoh (Sample Condition) : BARU……………………………………..
10. Metode Pengambilan Contoh (Sampling Method) : RANDOM SAMPLING…………………………………………………………………………….
…………………………………………………………………………….
11. No & Tanggal Surat Tugas Pengambilan Contoh : 007 / ST-OD/ IGS / 10 / 2023 - 20/10/2023
(Number & date of Sampling Assignment Letter)

Distribusi Contoh (Sample

Jumlah Distribution)
Tipe dan atau Jumlah Contoh
Produk* Contoh Contoh Arsip
Nomer Item Populasi yang diwakili* (Quantity of
No Merek (Brand) (Total Lab Perusahaan
(Type and or Item (Represented Population) Sample)
Product) (Lab’s (Spare’s
Number)
Sample) Sample)

1 SBC SCOOTER(3+) ………………………… 1 8 4 4

Scooter 3+ non
electric
2 SBC Mainan karet 2 8 4 4

Fr.7501/IGS-1.0.Rev.03
 Formulir

RENCANA PENGAMBILAN CONTOH

(SAMPLING PLAN)
007 / ST-OD/ IGS / 10 / 2023

Animal jumping ,
bola baseball
3 SBC PANAH 1 8 4 4
PANAH & PISTOL
3+
4 SBC KITCHEN SET 1 8 4 4
MOBIL STUNT
TOPENG ROBOT
CHANGE
5 SBC LILIN 1 8 4 4

6 SBC RC CAR 3+ 1 14 7 7
RC CAR ELECTRIC
7 SBC KLERENG 3 6 3 3

8 SBC BARBIE (3+) 1 8 4 4

BONEKA BARBIE
9 SBC KERETA (3+) 1 14 7 7

10 SBC SKIPING (3+) 1 8 4 4

11 SBC BALOK HIRUF 1 8 4 4

12 SBC PUZLE 1 8 4 4
PUZLE HEWAN

Fr.7501/IGS-1.0.Rev.03
 Formulir

RENCANA PENGAMBILAN CONTOH

(SAMPLING PLAN)
007 / ST-OD/ IGS / 10 / 2023

KAYU, PUZLE
SINGA KAYU
13 SBC BONEKA BICARA 1 14 7 7
(3+) ELECTRIC
14 SBC BONEKA HEWAN 1 6 3 3
KAIN
15 Sbc Soft active ball -3 1 8 4 4

Perusahaan/Pabrik Diverifikasi oleh Departemen Operasi Petugas Pengambil Contoh

(Company/Factory), (Verified by Operations Department), (Sampling Officer),

(..………………………..) (………………………….) (RONY)

Note: * isi bila diperlukan

Fr.7501/IGS-1.0.Rev.03