PT.

GLOSTAR INDONESIA
963廠 物品攜出單(Items release form)

Apply No : GTO20231204-134 Page : 1 of 2

Comp No : M-Class : Material
Fact : 963-ENG B S-Class : Subcontracting-Other
Dept : 0039-Engineering Gate：GERBANG GSI
Fact Area : GSI-1 Print Date : 2023/12/04

Carrier Carrier Dept Carrier Date 2023/12/05 Destination PT. NIKOMAS

ERNES WWTP GSI 1 GEMILANG
Return Mark Container No Transportatio By Others Transport
No Return F 1852 VA
n Vehicle Info
Expected Return Date Referance Form No Note OBAT CHECK LAB AIR WWTP GSI Invoice No
1

Item Material No Assets No Name of Goods Mat Style Unit Quantity Packag customs info1 customs info2 customs info3
No es
2604545 NITROGE
1 PACK 4 0
AMONIA
2429300 ZINC
2 PACK 1 0
REAGENT SET
2105869 TEMBAGA
3 PACK 1 0
TEST
2125815 COD
4 PACK 1 0
DIGESTION VIALS
1416066 BOD
5 PACK 5 0
NUTRIENT BUFFER
total 12 0
Please refer to Goods Gate Out Form -Customs department ID number Inquiry List

申請 R. ANNIESA A. 2023/12/04 16:32:44 Issue by

 PT. GLOSTAR INDONESIA
963廠 物品攜出單(Items release form)

Apply No : GTO20231204-134 Page : 2 of 2

Item Material No Assets No Name of Goods Mat Style Unit Quantity Packag customs info1 customs info2 customs info3
No es

Apply KUSUMAWARDHANI
審核 張傑雄 2023/12/04 18:33:33 R.Anniesa A.K
Verify
核定 劉凱仁 2023/12/05 07:45:36 Security guard
Approving SecurityGSI(GERBANG GSI)
officer 2023/12/05 08:11:39