Check list

HVDC
1JNL 1951823, B 1of 2
Adani Mumbai HVDC
Kudus-Aarey Approved HSE
Pepared (00
RGowthaman, 2022 1213 Mihtesh Kumar1, 2022-12-13

Workmen Soreening Fom

Site Ada ni mum bai HvDe, A%¢y.Date: 06
Name of the Contractor/Sub ractor kEC Inieaiona
Full Name of the worker:
ManowOY HLss ain
Fàher / Husband's Name:
Abde fabn Competency (Required/Not Required)
Designation Oferaloy Assessment
assessment: EÖTCrane operator, Backhoe (JCB) Loader Operator, Tnsck-Durmper
Folowing Designation need'mandatory competeney
Crane operator, Rigger, Pling ig operator, Fork ift-Skid Steer Loader operator, Excavator
andHeavy vehicle driver, Tractor Diver, Tower Welder, Gas Cutter, Grinder. Erection In Charge, Electrician,
Oherato. Driver, Crane operator, Scaffolding lnspector, Safety Supervisor,
Hesght Worke, Satety Olicer
Airt (qidih stagkhand-)S320
Permanent Address:

mahooshtra hanondi
Present Address

Gov. Photo ID Name &

Senial Number 4228 4os 2.9o41
Date of Birth 2S-o3 (924 Age 34
Covid Vaccination: 1"odgrd
Mobile Number 963724SGL2 (Atach Covid Vaccination Certiticate)
Marital Status Màrned /Single / Widow / Widower
Number of Children

Mother Tongue Hindi

Other Languages Known Hindi
In case of emergency, person to be
Contacted. (With address and 13212725S
Telephone Number if any)

Signature or Left-Hand Thumb

impresSion of the workmen

Education 84h eles.

Experience
Contractor Representative
Name vatmitPretad RANSAN KUNA R
Contractor Representative Sign
Date 612-28
PROPRIETARY AND SECRET NECRMATION

O Hitach Energy 2022. Al ights reservet

OHitachiEnergy
 Check list
HVDC Page
Documcnt nurnber. revsicn 2 of 2
1JNL1951823, B
Ttto
Workmen Screening Form

Medical Screening Annexure

Examining doctors name: Da Domioc Lobo Date:6_12/2023 Time: (_: 44 AM IP

encioged Identification Address/ Occupation
Father's Name Agel Sex Residence
Name Date of Birth Marks
be
should MerowWay Abd
34
male op M Ga wand Dr,ver
HusSain Ansn)
copy
Medical and occupational history:
report dist on1
Clinical Examination with particular reference to:
General Physique: G7o0d
Vision: Mor
for
etrs Hearing: NON MOy Height
Breathing: Nogmc weight 15kg
wer
report
to
V
Upper Limbs: Nomot bo
VI
Lower Limbs : Normy
VII. Spine :
VIlI. Blood pressure level:
S M indt
IX. Pulse &SPO2: 71931/

X
General (Mental alertness and siability with good eye, hand and foot coordination):
Anyother tests which the examining doctor considers necessary:

Ihereby pertíy that I bave personaly examined(name),..OnOWaN HuSssondaughteriwife of

...Ab....An9LAI. .residing at.1QWand..who is desirous of being employed in building and
construction work and that his/her age as nearly as can be ascertained from my examination is. ......51.....years
and that he/she is fit for employment in.....YAG. .as an adult/adolescent.
Blood
Group
org Reason for-1.Refusal of certificate

Signature/Left hand Thumb

OniniC
MBBS, MIRHLobo
- UK.
Signature with Seal 54094
Impression of worker dicai.indra
Medical nspectoriC.M.O oficer
O19314 5O
For Office Use
Site Engineeriln Chafge Site HSE OffGefiCoordinator
Name
Name Name
Sign Sign Sign
Admin for Gate Pass No:
Sign:
PROPRIETARY AND SECRET INFORNATION

@ Hitach1 Energy. 2022. A!I rights resered

taner
 DR. DARSHANA GADGIL
sainetra advanced eye care
MBBS, DNB, DO, FCPS, DOMS, ICO
CONSULTING OPHTHALMOLOGIST & LASIK SURGEON

A-103, Cosmos Park, Marol-Maroshi Road, Andheri (E), Mumbai -400 059. Mob :9769997775 /9769117775 /9769007775
E-mail: sainetravision@gmail.com Web: www.sainetra. in Follow us on :SaiNetra Advanced Eye Care ) Sai.netra.clinic
Age!
. Manowar Hussain

Opbthalomic ocss report

-:0o7-0 Xjo2
X Distnce vision botn cyes noT)e
Near vision botn eye norna

* Cotour vision btts eyes normad

ashaney
Antea Seqmnt
MBBS. DO.DNB.DOMS.FCPS
CONSULTING OPHTHALMOLOGIST

Postevo Segmnt
& LASIK SURGEON
REG. NO. 2000/03/1724
NETN
Rea. No.
7han6a0217365 )
lssue Date: 16/08/2017

25/03/1984 3041
7052
4228
9637295622
Mobile
No.:

Hussain
Manowar
DOB:
afI yoT/MALE
INDIA 001
Bengaluru-560
147,
a
AUTHORIEYOF No.
Box
P.O.

www.uldal.gov.in
825320
DENTIFIGATIONnawadih www
Downkoad Date: 11/03/2021 thana
-Jharkhand
panchayat
sarya
heipQuldal.gov.in
po Giridih,
UNNQUE nawadih
Ansari,
saraiya,
825320
-HIRGUGRahim
gram
iRG6,
HRUT, Barki
sariya,
Address:
Abdul 1800
1947
300

3IT2TT sariya,
block
1947
SIO:
 LMV-NTvIMOADEA
TRANS M.CYL Clsss SWDW Name
ABDUL Ot
PurpoTO.
HAZARIBAG
Holder
Card Badge
NeNEWAL MANOVWAR

20-0ctober-2014
Endorse
lssuoOn
INDIAN
HUSSAIN
Septeember-2013
mber-2013
No
23enA
DOB issue
25Dt.
Valldity()
Addross
NO.DL

JHARKHAND
STATE
JH-02DLROO00064
SignOf
UNION
thority
825320 H 20130
25-Mar-4984
NAWADI
JHARKHAND
GIRIDIH JH-02

r201s
Inc.CrgNo. valid
Haz SARYA0130064913 DRIVING
BADKIBiood
groupVelO+
lity
Endorse
Auth
SARYA
(NT),21-Sep-z033 LICENCE

DO0065028R
 pinted On: 17-0ct-2023 19:10:40
Ofice Copy

GOVERNMENT OF MAHARASHTRA
Motor Vehicle Dapartment
MUMBAI (EAST),Maharashtra

RECEIPUAPPL No MH3D231000004848/MH23101859977615
Vehicle Class: Excavator (NT)
Received From: MOBIN ISLAM ANSARI
Receipt Date: 17-Oct-2023 HAR3DXINTO3255094
Vehicle No: MH03EF4826 Chassis No: CHOLAMANDALAM
Sale Amount: 3200000/ FinancerName INVESTMENT &FINANCE

Transaction ld: MHY2310179678917 Bank Ref No:

Remarks: ONLINE-PAYMENT
Amount
Fine/Penalty/Addl.Fee Total
Particular
795
795
Road Safety Tax/Cess(16-Oct-2023to One Time) 15900
MV Tax(16-0ct-2023 to 30-Sep-2024) 15900
3000
3000
New Registration 3000
Hypothecation Addition 3000
200
Smart Card Fee 200
58 58
Postal Fee
AND FIFTY THREE ONLY)
GRAND TOTAL (in Rs): 22953/- (TWENTY TWO THOUSAND NINE HUNDRED
Note- This is computer generated slip, no need of signature (https:i/parivahan.gov.in).
INDIMOTECH
INDIMO TECH PRIVATE LIMITED

Printed On: 17-0ct-2023 19:10:40

Customer Copy

GOVERNMENT OF MAHARASHTRA
Motor Vehicle Department
MUMBAI (EAST),Maharashtra

RECEIPTIAPPL No: MH3D231000004848/MH23101659977615

Vehicle Class: Excavator (NT)
Received From: MOBIN ISLAM ANSARI
Receipt Date: 17-0ct-2023
Vehicle No: MHO3EF4826 Chassis No: HAR3DXINTO3255094
Sale Amount: 3200000/ FinancerName CHOLAMANDALAM
INVESTMENT & FINANCE
Transaction ld: MHY2310179678917 Bank Ref No:
Remarks: ONLINE-PAYMENT

Particular Amount Fine/PenaltylAddl.Fee Total

Road Safety Tax/Cess(16-0ct-2023 to One Time) 795 795

MV Tax(16-Oct-2023 to 30-Sep-2024) 15900 15900

New Registration 3000 3000
Hypothecation Addition 3000 3000
Smart Card Fee 200 200
Postal Fee 58 0 58
GRAND TOTAL (in Rs): 22953/- (TWENTY TWO THOUSAND NINE HUNDRED AND FIFTY THREE ONLY)
Note- This is computer generated slip, no need of signature (https:l/parivahan.gov.in).
INDIMOTECH
INDIMO TECH PRIVATE LIMITED
 COMMERCIAL General
Bajaj Allianz
VEHICUE.Insurance (o. Lid.POLICY. CERTIFICATE
MISC. PACKAGE
(uingly yons CUM PO.I(Y SCHEDLE
(FORM SI Or THE (NTRA MOTOR VEHF RUT ES 1989)
OBAJAJANanz(

RA1N)866
Policy Type: N Proposal No, &Date P2 3932882, 14 Oct 2023
20124 1 59PMIMdeis
Tenure IYear Pertod of Ineurance. 14Ot 2023 12.00AMto 13 Okt
MR MUDRIN ISLAM ANSARI
s d Name
IOTNO.47 1INT NO
Previous Policy Ne NA

Iured Add. ROXOM NO 4, RAGANWADI, GSTIN

GOVANDI, MUMBAI :27BPXPA2546C1ZX Prevtos 1nseret NA
MAHARASHIRA 400043
HASINA RAWEEN IRelation SPOUSE
|Age 27 |21AABCB$730G1ZX
PAN: RrXPA2SA6( GSTIN:
Commerce Zone. lt Floor, Tower . Samrat Adbok Path. Yerw Ada Pun AL02 DNTMAHARASHTRA-4110O6 State Code-z7
Sericing OMe of Insarer:
INSURED MOTOR VEHICLE DETALS INSURED DECLARED VALUE (TDV) On Re)
JCB Vehlele 1DV
Model-Variant DX-STD Non-Elec. Accessorles
Fuet Tpe DIESEL
Registration No,-RIO New- MUMBAI JCNGLPG Kit
ME Vear-Carrier Type 2023-PUBLIC Traller
Chaxsis No. H00391478- HARDXINTO3255094 IDV of Body
3040000
Hpecationlease Yes JTotal 1DV
Reg Date-Trailer RegNo
Vehicle Type-Sub Class MISC-Backhoe|
Cubic Capacity 123 Seating capacity
Schedule of Premium (Amount in Rs.)
Own Damage Premium (A) Liability Premium (B)
Basic Third Party Liab1lty (includ1ng TPPD) 7.267
Basic Premium
Vehicie 5,509 Thrd Party Liab1l1ty For B1-Fuel Kit
Trailer (MT - 30) 0 Tratler (IMT 30
Legal liabl1ty to Dr1ver ()/Cleaner & Coolie (0) / Helper (0) /
Non-Elec Accessories Conductor (0) (MT- 28
0 PA Cover For Ow ner Driver Of Rs. 1,500, 000 375
Elcc. Acessories ((MI-24) 0 PA Cover For Persons other than Owner Driver I20
CNGLPG Kit (IMT- 25)
Sub Tetal (Basic Premium) 5,509 Non Fare Paying Passenger (0) (IMT- 37)
Geographical Area Extension (IMT-1) o Geographical Arcas Extention (IMT- 1)
IMT- 23 827 IMT.34 TP
IMT- 34 o Net Liability Premium (B) 7812

Overturn 4560 Total Premium (A+B) 19,620

SGST(9.00%) 1766
Add On (GoldConsumables) 912
CGST(9.00 %) 1766

Total Add On 912

otal-Addition 1,808|Gross Premium Paid 23,132

Deaoctibles Note: 1.Policy issuance is subject to realization of cheque

No ClainBonus (0%) ogehd ted stamn tuty naid t stat exches uer

Sub Total (Deductibles) 0 3The policy is subject to Compulsory Excess 05% of lDV of the vehicle subject to a munumum af Ra 20004- (MT 1
11.808 4.Geographical Area-Ind1a
Net Own Damage Premíum (A)
"Subiect to IMT Endt. Nos & Memorandum.!7 22.3.285

Nominee Detaiks Nominee Name HASINA PRAWEEN Age 27Relation SPOUSE

L Payment Detail Payment Method Cheque No/ Transaction No Bank Name Amount
Dealer's Cheque/ DD
Fimancer Type Financer Name CHOLAMANDALAM Financer Branch MUMBAI
INVEST& FINANCE CO
TD
Timitatoss as to use. The policycovers use of the vehicle for any purpose other than () Hre or Reward (2) Carriage of goods (oher than samples or personal luggage) (3) Organ1zed ra Dg4
Pacemaking (5) Spced testing (6) Relability trials (7) Any purpose in connection with motor trade
Driver's Caust: Any person including the insured: Provided that the person driving tholds an effective driving license at the time ot the aceident and ks not disqualitied from hciding r coialing vuc
drive the vehicle & thal such a person satisfies the requrements of Rule 3 of the ('ental Mewr enicles Ries,
lacense. Provided also that the person hold1ng an effective learner?"?s license may
1989.

Limits of Lisbility Clase: Under Secton ll 6)of the policy-Death of or bodily injury: Such amount as is necessary to meet the requrements of the Moior Vehicke At 988 Under Setoa llla) ot
the policy.Damage to dhard party praperty s Bs 7.5 laahs,PACover Under Section (llfor Owner-Driver is Rs 1,500.,000
Grievance Clause: For resotion of any query or grievance, Insured nay check Gnevance redressal policy al htps//www. bajajallianZ. convsbout-us/customer- seryke huni or conet with the
respective servicing offxe of LnsuEaNCe company. fn the event of unsatisfackory response, helshe may approach he msurance ombudsman for the redressal of wuevake at or oa website t ieneral
ne Cuncit
Hypothecation Details: CHOLAMANDALAM INVEST &FINANCE COLTD, MUMBAI MISP Name -INDIMO TECH PRIVATE LIMITEDMSP Code "AB-MJBO00057
DP Name: BHARAT sUDHAKAK KULKAKNIDP Code: AB-DPJB000053-0860
Important Notice: The insurd ts hot indenn1ficd, if the vehcle is used or driveh otherwise than in sccotdance wih he scheduke. Any paymeot made by he comanv hy reasons of widcer tems
apnearing in the certificate in order to comply with the Motor Vehicie Act, 1988 is receverable from the asured See the clause headed "AYODANE OR CERTA N TERMs &RIGHTOF
ECOVERy" For legal interpretation, English version will hold good

Description of Service : Motor Insurance Insurer Invoice Number

SAC 997134 Place of Supply :MAHARASHTRA(Sate Code-27)
JBA/L000508661
/we hereby certify that the policy to which this cetificate relates as well as this certificate of insurance are issued in accordance with the provisions of Chapter X and ChApterXI of Motor Venicie A
 Back Hoe Loader Operator Competerncy Assess HITACHI
PREPAREO BY

Geeta Baliyan
APPROVE RY APPROVAM DATE Inspire the Next
Saroy Burman 2022-11-11
STAIUS sECURrtY LEVEI D0CMEN
Approved Publc 1JNL1246A08
OHtachi Energy Tecnology Servic vte Limited

Fit/Unfit
Adani Murmbai HVDC Project
Back Hoe Loader Operator Competency Assessment
Name of the worker
Supervisor Name Rorsun kumar
Age 39
Aadhar/Govt I) 422810S2 3047
Experience
License Number
SH-0220130064q13
Eye test report (Power Glass needed/ No vision related issues)
SINo Assessment Criteria for outcomes Result Assessor Commert
Check and adjust the operator seat., seatbelts and set them as
1
per
comtort level
Before operation, ensure that no one is beneath or on the ma
chine
3
Examine the body of thebackhoe loader tocheck that it is
free of cracks and wear
4 Set the rear and side mirrors for correctviewing position
5 Check for leaks in the hydraulichoses andcylinders
6 Carry out inspections toverify that the parking brake, main horn, ok
reverse horn, andheadlight are in proper workingorder
7 Check battery electrolyte level and terminaltightness ole
Inspect the different controls,gauges, warning lights, and confirm
that all safety andmaintenancestickers are present
Safe reversing and speed limite
10 Make sure that all the pins,bushings andpivot points are
property greased
11 Awareness on Fire extinguisher usage
12 Awareness Periodic maintenance and daily checks
Tick on the appropriate: ok
Experienced Certified(With Qualification) Fresher - MO

1s years
Name &Designation of the Assessor AranhDufA
Signature of the Assessor Date: 06- 12:23

OHitachi Energy
 Documont No. KECAMSEHS/07/FI43
02 Røv. No. 00
Issue. No.
KEC CHECKLIST FOR JCB Issue. Date 08-12-2018 Rev. Date 00-00-00

Page No.

Equipment No. MHog EEq?26

Project Name:
HVpS lorey site Inspection Date: 06-12-2?
Contractor Name:
KEC
Inspected by: |Vehicle Registration No. MHO3 EFY826
5 7
9

10
8

NO REMARKS
DESCRIPTION YES
SR. NO
Front & reverse horn in working
1 condition
Head & tail lamps (for working at
yes
2 night) in working condition yes
Leakage of oil in hydraulic
3 systems observed.
Bolts / connecting pins (bucket)
4
are loose.
5 Rear view mirror without damage.
Hydraulic oil level available
6 (max/min)
Structure beam condition without
es.
7 damage /cut / crack
|Diesel,oil and grease spillage
yyes
8
observed.
Out riggers in working condition
Vehicle Insurance available
yes.
10 (mention due date) yo. 13 oef-2024y
11 Operator license available yes plo220I3006991
12
Equipment Fitness Certificate
available ye L6 oek208?

Signature:
Designation: