Contract No.

: 615/PPK-
REV
MAF/-1.799.21
RENCANA INSPEKSI & PENGUJIAN DI LAPANGAN DOC. NO.: 1
BRDF-QAC-PCD-100.007
(FIELD ITP) UNTUK PEKERJAAN PERPIPAAN DATE BY CHKD APVD
6-Jun-22 CPI CPI CPI

RESPONSIBILITY
METODE
No. AKTIVITAS INSPEKSI DOKUMEN REFERENSI DOKUMEN VERIFIKASI KET
INSPEKSI Subkon KONT PEMILIK

1.0 PIPING WORKS/FABRICATION

1.1 MATERIALS
a. Material Verification Review Mill Certificate QI-M0.01 P R R
b. Type / Size / Grade / Schedule Dimensional Project Spec., Material List QI-M0.01 M W SW
c. Quantity / Quality Material Inspection Visual & Review Packing List QI-M0.01 M W SW

1.2 FABRICATION / FIT-UP

a. Identification / Weld Map Review Drawing Approved QI-L-02 M R R
b. Tack Weld Satisfactory Visual Drawing Approved QI-L-02 M SW SW
c. Conformity To Isometric Drawing Visual Drawing Approved QI-L-02 M W SW
d. Weld Identification Visual Drawing Approved QI-L-02 M W SW

1.3 WELDING
a. WPS & PQR Review and Performance Review ASME Sec.IX WPS / PQR P P/R R
b. Welders Performance Qualification Test Visual & Review ASME Sec.IX Welder Certificate M W SW
c. Consumable Control Review ASME SEC.II C/Mfd. standard QI-G.02 M SW R
d. Preheat ( if req. ) Visual & Review ASME B31.3 QI-L-02 M SW R
e. Complete Weld Visual ASME B31.3 QI-L-02 M W SW
f. Visual Inspection Visual ASME B31.3 QI-L-02 M W R
g. Weld Travel Sheet Review Drawing Approved QI-L-05 P R R

1.4 INSTALLATION
Piping works Installation Check List
a. Visual Project Spec. Drawing Approved QI-L.09 M W SW
(Under Ground Piping)
Piping works Installation Check List
b. Visual Project Spec. Drawing Approved QI-L.08 M W SW
(Above Ground Piping)
c. Punchlist Visual Drawing Approved Punch List M W SW
 Contract No. : 615/PPK-
REV
MAF/-1.799.21
RENCANA INSPEKSI & PENGUJIAN DI LAPANGAN DOC. NO.: 1
BRDF-QAC-PCD-100.007
(FIELD ITP) UNTUK PEKERJAAN PERPIPAAN DATE BY CHKD APVD
6-Jun-22 CPI CPI CPI

RESPONSIBILITY
METODE
No. AKTIVITAS INSPEKSI DOKUMEN REFERENSI DOKUMEN VERIFIKASI KET
INSPEKSI Subkon KONT PEMILIK

2.0 NON DESTRUCTIVE TEST

2.1 RADIOGRAPHIC TEST
a. RT Procedure Approval Review ASME Sec. V Procedure Approped P R R
b. Personnel Qualifications Review Certificate Personel Certificate P R R
c. Identification Of Joints Review Drawing Approved Welding Map/IFC Drawing M W R
d. Perform Test Visual ASME B31.3 QI-L.14/ Subcont. Report M SW R
e. Evaluate Of Results Review ASME B31.3 QI-L.14/ Subcont. Report M R R

2.2 DYE PENETRANT TEST

a. PT Procedure Approval Review ASME Sec. V Procedure Approped P R R
b. Personnel Qualifications Review Certificate Personel Certificate P R R
c. Identification Of Joints Review Drawing Approved Welding Map/IFC Drawing M W R
d. Perform Test Visual ASME B31.3 QI-L.13/ Subcont. Report M SW R
e. Evaluate Of Results Review ASME B31.3 QI-L.13/ Subcont. Report M R R

2.3 MAGNETIC PARTICLE TEST ( if req. )

a. MPT Procedure Approval Review ASME Sec. V Procedure Approped P R R
b. Personnel Qualifications Review Certificate Personel Certificate P R R
c. Identification Of Joints Review Drawing Approved Welding Map/IFC Drawing M W R
d. Perform Test Visual ASME B31.3 QI-L.12/ Subcont. Report M SW R
e. Evaluate Of Results Review ASME B31.3 QI-L.12/ Subcont. Report M R R

3.0 PRESSURE TEST

a. Pressure Test Procedure Review ASME B31.3 Procedure Approve P R R
b. Completion of System and Test Method Review Procedure Approved Subcont. Method P R R
c. Line Checking Review Drawing Approved Ql-L.06 M W R
d. Test Package Approval Review Report Test Pack Index P/M R R
 Contract No. : 615/PPK-
REV
MAF/-1.799.21
RENCANA INSPEKSI & PENGUJIAN DI LAPANGAN DOC. NO.: 1
BRDF-QAC-PCD-100.007
(FIELD ITP) UNTUK PEKERJAAN PERPIPAAN DATE BY CHKD APVD
6-Jun-22 CPI CPI CPI

RESPONSIBILITY
METODE
No. AKTIVITAS INSPEKSI DOKUMEN REFERENSI DOKUMEN VERIFIKASI KET
INSPEKSI Subkon KONT PEMILIK

e. Equipment of Test approval Visual Certificate QI-L.07/QI-L.07.01 M R R

f. Calibration of Gauges Review Certificate QI-L.07/QI-L.07.01 P R R
g. Hold and Check for Leaks Pressure test Visual Procedure Approved QI-L.07/QI-L.07.01 P/M W SW
h. Accept Test Visual Procedure Approved QI-L.07/QI-L.07.01 M R R

4.0 PVC & HDPE PIPING WORK

a. Procedure Review Review Procedure Approved Subcont. Method P R R
b. Material Check & Data sheet ( MSDS ) Visual Manufacturer's Spec Manufacture Std P/M R R
c. Surface Preparation & Fit-up Check Visual Manufacturer's Spec Ql.Pl.03 M SW SW
d. Apply Jointing Visual Manufacturer's Spec Manufacture Std M SW SW
g. Visual joint Visual Manufacturer's Spec Ql.Pl.04 M W SW
h. Leak test (Pressure Test) Test Project Spec. QI-L.07/QI-L.07.01 M W SW

5.0 PAINTING WORK / TOUCH -UP

a. Procedure Review Review Procedure Approved Subcont. Method P R R
b. Material Check & Data sheet ( MSDS ) Review Manufacturer's Spec Manufacture Std P/M R R
c. Surface Preparation Check Visual Project Spec. QI-N.01/QI-N.01.01 M W SW
d. Visual & DFT Check Visual Project Spec. QI-N.01/QI-N.01.01 M W SW

6.0 WRAPPING WORK (Under Ground Piping Work )

a. Procedure Review Review Procedure Approved Subcont. Method P/R R R
b. Material Check & Data sheet ( MSDS ) Visual Manufacturer's Spec Manufacture Std P/M R R
c. Surface Preparation Check Visual Project Spec. QI-N.03 M W SW
d. Visual Inspection Visual Project Spec. QI-N.03/QI-N.03.01 M W SW
e. Holiday Test Test Project Spec. QI-N.03/QI-N.03.01 M W SW

7.0 RE-INSTATE PIPE WORK

 Contract No. : 615/PPK-
REV
MAF/-1.799.21
RENCANA INSPEKSI & PENGUJIAN DI LAPANGAN DOC. NO.: 1
BRDF-QAC-PCD-100.007
(FIELD ITP) UNTUK PEKERJAAN PERPIPAAN DATE BY CHKD APVD
6-Jun-22 CPI CPI CPI

RESPONSIBILITY
METODE
No. AKTIVITAS INSPEKSI DOKUMEN REFERENSI DOKUMEN VERIFIKASI KET
INSPEKSI Subkon KONT PEMILIK

a. Check Permanent Pipings components and accessories Visual Drawing Approved QI - L.10 M W SW
b. Check Permanent Piping and Instruments Visual Drawing Approved QI - L.10 M W SW
c. Check Permanent Gaskets Visual Drawing Approved QI - L.10 M W SW
d. Bolts Tigtening
- Manual Tigtening Visual Engineering Specification QI - G.01.01 M SW R
- Hydraulics Bolt Tensioning Visual Engineering Specification QI - G.01/Subcont Report M SW R
e. Final Punch list Visual Drawing Approved Punch list report M W SW

8.0 FINAL DOCUMENT / REPORTING ACTIVITIES Review Procedure Approved Report Dossier P R R

Legend :
Subkont : Subkontraktor P : Issued / Provided Document
KONT : KONTRAKTOR, ADHI-JAKON KSO M : Mandatory, Subcont Inspection/Test performed by
PEMILIK : PEMDA DKI the Subcont at site
R : Review
W : Witness Point
SW : Spot Witness Point
 CONTRACT NO. :
REV
06/V00000/2018-S0
FIELD INSPECTION AND TEST PLAN DOC. NO.:
001
26072-203-GQI-GCQ-G0015
FOR PIPING WORKS DATE BY CHKD APVD
2-Dec-19 GAM CPI IFN

RESPONSIBILITY
METHOD OF LEVEL OF ACCEPTANCE /
No. INSPECTION ACTIVITY/TEST ITEM VERIFYING DOCUMENT REMARKS
INSPECTION REFERENCE S/C CONT. OWNER MIGAS

1.0 INSPECTION INCOMING MATERIAL

a. Material Verification Review Mill Certificate QI-M0.01 R R
b. Type / Size / Grade / Schedule Dimensional Material Requisition QI-M0.01 W SW
c. Quantity / Quality Material Inspection Visual & Review Material Requisition & Packing List QI-M0.01 W SW
d. PMI ( For Alloy / SS ) Test Mill Certificate Inspection Report W SW

2.0 PIPING WORK / FABRICATION

2.1 FABRICATION / FIT-UP
001
a. Marking Identification Spool Review Shop Drawing QI-L-02 M R R
b. Cut Length (Check Transfer of Heat N0. & Dimensional Check) Visual Shop Drawing QI-L-02 M W R
c. Bevel Angel, gap, HI-LO Visual Shop Drawing QI-L-02 M W R
d. Levelness, Alignment Visual Shop Drawing QI-L-02 M W R
e. Conformity To Isometric Drawing Visual Shop Drawing QI-L-02 M W R
V
f. Weld Identification Visual Shop Drawing QI-L-02 M W R

2.2 WELDING / Weilding Repair

a. WPS & PQR Review ASME IX WPS / PQR P R
b. Welders Performance Qualification Test Visual & Review ASME IX Welder Certificate M W SW
c. Consumable Control Review ASME SEC.II C/Mfd. standard QI-G.02 M W R
d. Pre-Heat ( If Requered) Visual & Review ASME B31.3 QI-L-02 M W R
e. Complete Weld Visual ASME B31.3 QI-L-02 M W SW
f. Visual Inspection Visual ASME B31.3 QI-L-02 M W W
g. Weld Travel Sheet Review Wellding Book of Piping QI-L-05 P R R

2.3 Welding Repair 001

a. WPS & PQR Review ASME IX WPS / PQR P R
b. Welders Performance Qualification Test Visual & Review ASME IX Welder Certificate M W SW
c. Consumable Control Review ASME SEC.II C/Mfd. standard QI-G.02 M W R
d. Pre-Heat ( If Requered) Visual & Review ASME B31.3 QI-L-02 M W R
e. Complete Weld Visual ASME B31.3 QI-L-02 M W SW
f. Visual Inspection Visual ASME B31.3 QI-L-02 M W W V
g. Weld Travel Sheet Review Wellding Book of Piping QI-L-05 P R R

2.4 INSTALLATION

Piping works Installation Check List (Under 26072-203-3SS-P34-G0003 & 26070-

a. Visual QI-L.09 M W SW
Ground Piping) 100-3SS-PB00-J0004

Piping works Installation Check List (Above 26072-203-3SS-P34-G0003 & 26070-

b. Visual QI-L.08 M W SW
Ground Piping) 100-3SS-PB00-J0004
c. Punchlist Visual Drawing Approved Punch List M W SW

3.0 NON DESTRUCTIVE TEST / NDE Before and After PWHT

3.1 RADIOGRAPHIC TEST
a. RT Procedure Approval Review ASME Sec. V Procedure Approped P R R
 CONTRACT NO. :
REV
06/V00000/2018-S0
FIELD INSPECTION AND TEST PLAN DOC. NO.:
001
26072-203-GQI-GCQ-G0015
FOR PIPING WORKS DATE BY CHKD APVD
2-Dec-19 GAM CPI IFN

RESPONSIBILITY
METHOD OF LEVEL OF ACCEPTANCE /
No. INSPECTION ACTIVITY/TEST ITEM VERIFYING DOCUMENT REMARKS
INSPECTION REFERENCE S/C CONT. OWNER MIGAS

b. Personnel Qualifications Review Certificate Personel Certificate P R R

c. Identification Of Joints Review Project Spec. Welding Map/Line Class M W R
d. Evaluate Of Results Review ASME Sec. VIII or ASME B31.3 QI-L.13/ Subcont. Report M R R
 CONTRACT NO. :
REV
06/V00000/2018-S0
FIELD INSPECTION AND TEST PLAN DOC. NO.:
001
26072-203-GQI-GCQ-G0015
FOR PIPING WORKS DATE BY CHKD APVD
2-Dec-19 GAM CPI IFN

RESPONSIBILITY
METHOD OF LEVEL OF ACCEPTANCE /
No. INSPECTION ACTIVITY/TEST ITEM VERIFYING DOCUMENT REMARKS
INSPECTION REFERENCE S/C CONT. OWNER MIGAS

3.2 DYE PENETRANT TEST

a. PT Procedure Approval Review ASME Sec. V Procedure Approped P R R
b. Personnel Qualifications Review Certificate Personel Certificate P R R
c. Identification Of Joints Review Project Spec. Welding Map/Line Class M W R
d. Perform Test Visual ASME Sec. VIII or ASME B31.3 Subcont. Report M W SW
e. Evaluate Of Results Review ASME Sec. VIII or ASME B31.3 QI-L.13/ Subcont. Report M R R

3.3 MAGNETIC PARTICLE TEST (If Requered)

a. MPT Procedure Approval Review ASME Sec. V Procedure Approped P R R
b. Personnel Qualifications Review Certificate Personel Certificate P R R
c. Identification Of Joints Review Project Spec. Welding Map/Line Class M W R
d. Perform Test Visual ASME Sec. VIII or ASME B31.3 Subcont. Report M W SW
e. Evaluate Of Results Review ASME Sec. VIII or ASME B31.3 QI-L.12/ Subcont. Report M R R

3.4 ULTRASONIC TEST

a. UT Procedure Approval Review ASME Sec. V Procedure Approped P R R
b. Personnel Qualifications Review Certificate Personel Certificate P R R
c. Identification Of Joints Review Project Spec. Welding Map/Line Class M W R
d. Perform Test Visual ASME Sec. VIII or ASME B31.3 Subcont. Report M W SW
e. Evaluate Of Results Review ASME Sec. VIII or ASME B31.3 QI-L.15/ Subcont. Report M R R

4.0 POST WELD HEAT TREATMENT (PWHT)

a. PWHT Procedure Approval Review ASME Sec. VIII & ASME B31.3 Procedure Approved P R R
b. Equipment Approval Visual & Review Certificate Certificate Approved P R R
c. Identification Of Joints Visual Drawing Approved AFC Shop Drawing M W R
d. Perform Test Visual & Review ASME Sec. VIII & ASME B31.3 QI-L.16/ Subcont. Report M SW SW
e. Evaluate of Results Review ASME Sec. VIII & ASME B31.3 QI-L.16/ Subcont. Report M R R

5.0 HARDNESS TEST

a. Hardness Test Procedure Approval Review ASME B31.3 Procedure Approped P R R
b. Equipment Approval Visual & Review Certificate Certificate Approved P R R
c. Perform Test Visual & Review NACE MR.0175 & ASME B31.3 QI-L.17/ Subcont. Report M SW SW
ASME B31.3 & 26070-100-3SS-
d. Evaluate Test Results Review QI-L.17/ Subcont. Report M R R
NWPO-J0003

6.0 PRESSURE TEST

a. Pressure Test Procedure Review ASME B31.3 Procedure Approved P R R
b. Completion of System and Test Method Review Procedure Approved Subcont. Method P R R
c. Line Checking or Punch list Review Drawing Approved Ql-L.06 M W W
d. Test Package Approval Review Report Test Pack Index P/M R R
e. Equipment of Test approval (Manifold) Visual Certificate QI-L.07/QI-L.07.01 M R R
f. Calibration of Gauges Review Certificate QI-L.07/QI-L.07.01 P R R
h. Hydostatic Test or Pneumatic Test Visual Procedure Approved QI-L.07/QI-L.07.01 P/M W SW
 CONTRACT NO. :
REV
06/V00000/2018-S0
FIELD INSPECTION AND TEST PLAN DOC. NO.:
001
26072-203-GQI-GCQ-G0015
FOR PIPING WORKS DATE BY CHKD APVD
2-Dec-19 GAM CPI IFN

RESPONSIBILITY
METHOD OF LEVEL OF ACCEPTANCE /
No. INSPECTION ACTIVITY/TEST ITEM VERIFYING DOCUMENT REMARKS
INSPECTION REFERENCE S/C CONT. OWNER MIGAS

7.0 PAINTING WORK / TOUCH -UP

a. Procedure Review Review Procedure Approved Subcont. Method P R R
b. Material Check & Data sheet ( MSDS ) Review Manufacturer's Spec Manufacture Std P/M R R
c. Surface Preparation Check Visual 26070-100-3SS-NX00-J0-100 QI-N.01/QI-N.01.01 M W R
d. Visual & DFT Check Visual 26070-100-3SS-NX00-J0-100 QI-N.01/QI-N.01.01 M W SW

8.0 INSULATION
a. Procedure Review Review Procedure Approved Manufacture Std P R R
b. Material Check & Data Sheet (MSDS) Visual Manufacturer's Spec Manufacture Std P/M SW R
c. Surface preparation cleaning Visual 26072-3SS-P34-G0005 QI-N.02 M SW R
d. Jacketing installed and sealed per specification Visual 26072-3SS-P34-G0005 QI-N.02/QI-N.02.01 M SW R
e. Visual Inspection Visual 26072-3SS-P34-G0005 QI-N-02 M W SW

9.0 WRAPPING WORK (Under Ground Piping Work )

a. Procedure Review Review Procedure Approved Subcont. Method P/R R R
b. Material Check & Data sheet ( MSDS ) Visual Manufacturer's Spec Manufacture Std P/M R R
c. Surface Preparation Check Visual 26072-3SS-P34-G0011 QI-N.03 M W R
d. Visual Inspection Visual 26072-3SS-P34-G0011 QI-N.03/QI-N.03.01 M W SW
e. Holiday Test Test 26072-3SS-P34-G0011 QI-N.03/QI-N.03.01 M W SW

10 ACID PICKLING STAINLESS STEEL WELDMENTS

a. Procedure Review Review Procedure Approved Manufacture Std P R R
b. Material Check & Data Sheet (MSDS) Visual Manufacturer's Spec Manufacture Std M SW R
c. Surface preparation cleaning Visual 26072-203-3SS-P34-G0010 QI-L.04 M SW R
d. Applied pikling completion & remove any residual pikling solution Visual 26072-203-3SS-P34-G0010 QI-L.04 M SW R
e. Visual Inspection Visual 26072-203-3SS-P34-G0010 QI-L.04 M W SW

11 RE-INSTATE PIPE WORK

a. Check Permanent Pipings components and accessories Visual Drawing Approved QI - L.10 M W SW
b. Check Permanent Piping and Instruments Visual Drawing Approved QI - L.10 M W SW
c. Check Permanent Gaskets Visual Drawing Approved QI - L.10 M W SW
d. Bolts Tigtening
- Manual Tigtening Visual 26070-100-3GS-FB00-JD001 QI - G.01.01 M W R
- Hydraulics Bolt Tensioning ( If Requered) Visual 26070-100-3GS-FB00-JD001 QI - G.01/Subcont Report M W R

12 MECHANICAL COMPLETION OF PIPING WORKS

a. Final Punch list Visual Drawing Approved Punch list report M W SW
b. Mechanical Completion of Pipe Works Visual Drawing Approved QI-L.11 M W SW

13 FINAL DOCUMENTATION / DOSSIER Review Report Approved MDR Report P P R

 FORM NO. QI-Pl.03
PEMBANGUNAN FASILITAS PENGOLAHAN SAMPAH LANDFILL REPORT NO :
MINING DAN RDF PLANT (RANCANG DAN BANGUN) DATE :
PAGE :
FIT-UP PIPING FOR PVC & HDPE Project No.:
PIPING MATERIAL CLASS :

JOINT JOINT FIT-UP

ISOMETRIC DRAWING NO LINE NO. COMPONENT SIZE DIA" SCH THK REMARKS
NO. ACCEPT REJECT

SUBCONTRACTOR CONTRACTOR OWNER

SIGNATURE

NAME
DATE
 FORM NO. QI-PI.04
PEMBANGUNAN FASILITAS PENGOLAHAN SAMPAH LANDFILL REPORT NO :

MINING DAN RDF PLANT (RANCANG DAN BANGUN) DATE :

PAGE :
VISUAL JOINT FOR PVC & HDPE Project No.:
DWG NO : REV : SHEET
LINE NO :
PIPING MATERIAL CLASS :

VISUAL INSPECT RESULT FIT-UP

JOINT SIZE SCH SIZE SCH REPORT
COMPONENT MATERIAL HEAT NO. BONDER FITTER DATE REMARKS
NO. DIA" THK DIA" THK NO.
ACCEPTED REJECTED

SUBCONTRACTOR CONTRACTOR OWNER

SIGNATURE

NAME
DATE
 FORM NO. DATE
BANGGAI AMMONIA PLANT Ql-PI.04.01
PROJECT Report No.

Subject : GRE PIPING (CHECK LIST) Project no : 15-8803

SYSTEM : AREA :
P&I D DRAWING NO. : ISOMETRIC DWG NO. :
REFERENCE NO. : DOCUMENT NO. :

RESULT
No. INSPECTION/TEST ITEM SIGNATURE DATE REMARKS
YES N/A
1 MATERIAL :

a. Check material accepted

b. Visual & dimensional check

2 PRE-JOINT INSPECTION :

a. Check consumable material

b. Surface align & cleaning

c. Check application joint & cure resin putty

3 POST JOINT INSPECTION :

a. Check step by step lamination process of joint

b. The position overlap shall be staggered

After the laminate of the last process is cure,
c. grind/ snad the joint surface smoothly then
continue by apply of catalyzed top coat resin.
4 FINAL INSPECTION :

a. Visual & dimensional

b. Hydro test

Remarks :

Prepared by Checked by Approved by

Sub-Contractor CONTRACTOR OWNER
 Prepared by Checked by Approved by
Sub-Contractor CONTRACTOR OWNER
Print Name

Signature

Date
`
: 15-8803

REMARKS
 Date :
FORM NO. QI - M0.01
RELOKASI FLARE BPP II & NEW FLARE HCC
RU V PERTAMINA BALIKPAPAN Report No. : Page :
of

Subject : QUALITY INSPECTION MATERIAL REPORT JOB NO:

MATERIALS DETAIL

INSPECTION DATE : SUPPLIER :

MRR NO : PURCHASE ORDER NO. :

Detail of Shipment P.O DATE :

Packing List No. : No. OFF PACKAGE :

Delivery Date : BATCH NO :
Receiving Date :

DESCRIPTION OF MATERIAL :

QUANTITY :

DELIVERY INSPECTION INSPECTION REPORT

MATERIAL RECEIVED RECOMENDATIONS

RESULT RESULT
YES NO YES NO

QTY MT'L COMPLETED : APPROVED :

OVER : APPROVED, WITH NOTE (see OSDR) :
SHORTAGE : REJECTED/QUARANTINED(see NCR) :
DAMAGE : NON CONFORMANCE REPORT (NCR NO. ) :
DOCUMENTATION NCR REPORT DATE :
Completed Not Completed

OVER /SHORTAGE /DAMAGE REPORT (OSDR)

ROOT CAUSE / NOTES :

Remarks :

Logistic CONTRACTOR OWNER

Inspected/Accepted Review/Verify
Print Name

Signature

Date
 PEMBANGUNAN FASILITAS PENGOLAHAN FORM NO. QI-G.01
REPORT NO. :
SAMPAH LANDFILL MINING DAN RDF PLANT DATE :
(RANCANG DAN BANGUN)

SUBJECT : BOLT TORQUING INSPECTION REPORT (Hydraulics Bolt Torque)

DRAWING
LINE NUMBER : LINE NUMBER :
DRAWING NO. :
PIPING MATERIAL CLASS :
DRAWING NO :

MATERIALS
DESCRIPTION FLANGE BOLT GASKET
Diameter (inch)
Rating # (Lb)
Thickness (mm)
Material Type
Length (mm)
Quantity (pcs)
Bolt Torque Value (lbf.ft/Psi)

PRESSURE GAUGE
SERIAL/TAG NO. CALIBRATION CERTIFICATE VALIDITY MAXIMUM TORQUE CAPACITIES

COMPONENT MATERIAL OF BOLT TORQUE :

- FLANGE TO FLANGE
- FLANGE TO VALVE
- FLANGE TO NOZZLE EQUIPMENT

INSPECTION RESULT : ACCEPTED / REJECTED

REMARKS ; Drawing as per attached

COMPLETED BY SUBCONTRACTOR CONTRACTOR OWNER

SIGNATURE

NAME
DATE
 FORM NO. QI-G.01.01
PEMBANGUNAN FASILITAS PENGOLAHAN
SAMPAH LANDFILL MINING DAN RDF PLANT DATE :
(RANCANG DAN BANGUN)
JOB NO. :
SUBJECT : BOLT TORQUING INSPECTION REPORT (Manual Tightening Bolt)
EQUIPMENT NO: LINE NO. :
TESTPACK No. : ISOMETRIC NO :

Engineering Data:

Manufacturer: .......................... Test Certificate Available: YES / NO

Torque Range: .......................... Certificate Number: ..........................

Results :

JOINT NO: BOLT SIZE QTY TORQUE READINGS (Nm) JOINT NO: BOLT SIZE QTY TORQUE READINGS (Nm)

Remarks:

COMPLETED BY SUBCONTRACTOR CONTRACTOR OWNER

SIGNATURE

NAME
DATE
 FORM NO : QI -G.02

ELECTRODE BAKING RECORD

JOB NO :
PROJECT TITLE :
CONTRACTOR :
OWNER :
LOCATION :
ELECTRODE QUANTITY BATCH / SERIAL TIME BAKING INSPECTION CHECK
DATE SIZE REMARKS
BRAND ( KG ) NO. IN OUT TEMP. (OC) CONTRACTOR OWNER
 Date :
PEMBANGUNAN FASILITAS PENGOLAHAN SAMPAH LANDFILL MINING
QI-L.02
DAN RDF PLANT (RANCANG DAN BANGUN) Page :

SUBJECT : DAILY WELDING REPORT FOR PIPING Report No.

COMPONENT OF JOINT No. WELD WELDER FIT-UP FINAL VISUAL

MATERIAL SPEC. WPS No. DRAWING No. DIA SCH REMARKS
MATERIAL SW FW TYPE STAMP ACC REJ ACC REJ

Note : SW : Shop weld BW : Butt weld SOF : Slip on Flange Final vis : Final visual
FW : Field weld FW : Fillet Weld SOB : Stub on Branch LET : Sockolet

Prepared By Approved By : Approved By :

Company Sub-Contractor CONTRACTOR OWNER
Sign
Name
Date
 FORM NO. QI-L.04
RELOKASI FLARE BPP II & NEW FLARE HCC RU V REPORT NO :

PERTAMINA BALIKPAPAN DATE :

PAGE : 1 OF 1
ACID PICKLING OF STAINLESS STEEL WELDMENTS Project No.:

JOINT JOINT PICKLING

ISOMETRIC DRAWING NO LINE NO. COMPONENT SIZE DIA" SCH THK REMARKS
NO. ACCEPT REJECT

SUBCONTRACTOR CONTRACTOR OWNER

SIGNATURE

NAME

DATE
 PROJECT TITLE : JOB NO :
PEMBANGUNAN FASILITAS PENGOLAHAN SAMPAH LANDFILL
MINING DAN RDF PLANT (RANCANG DAN BANGUN)
QI-L.05
TEST PACKAGE NO. PAGE : OF

WELD TRAVEL SHEET

DWG NO. : LINE NO. : WPS NO. : PQR NO. :

WELD JOINT NO. Process WELDER DATE RT ( Report No. )

UT
MATERIAL TYPE Welding Rod / DATE
COMPONENT
MATERIAL SPEC. DIA. SCH. BW FW Electrode G VISUAL
PT PWHT PMI HB REMARKS
SW FW STAMP WELDED ACC. REJECT ACC. REJECT ACC. REJECT
MT
TRD S

NOTE : RT ( Radiography Test ), UT ( Ultrasonic Test ), PT ( Penetrant Test ), MT ( Magnetic Test ), SW ( Shop Weld ), BW ( Butt Weld ), FW ( Fillet Weld ), BC ( Branch Connection Weld ), TRD ( Thread Connection ), G ( GTAW ), S (SMAW),

FINAL ACCEPTANCE
SUBCONTRACTOR CONTRACTOR OWNER
NAME
SIGN
DATE
 QI-L.06

Page : ……….. of …………..

LINE CHECK REPORT

Project Title :
Job No. :
Area :
Reference No. :
Document No. :
Test Package No. :

ISOMETRIC DRAWING CATEGORY TARGET DATE ACCEPTED

NO. COMMENTS / DESCRIPTION REMARKS
NO. A or B DATE CLEARED SUBCONT CONTRACTOR OWNER

Prepared by ; Checked by ; Approved by ;

SUBCONTRACTOR CONTRACTOR OWNER

Date : Date : Date :

Legend : A : Item shall be completed after pressure test

B : Item shall be completed before presure test
 Date :
PEMBANGUNAN FASILITAS PENGOLAHAN QI - L.07
SAMPAH LANDFILL MINING DAN RDF PLANT Test Package No. :
(RANCANG DAN BANGUN)
JOB No. :
SUBJECT: PRESSURE TEST RECORD

LINE UNDER TEST :

P & ID. NO :

DESIGN PRESSURE : Kg/cm2 or Bar (G)

TEST PRESSURE : Kg/cm2 or Bar (G)
DURATION OF TEST : hours/minutes

Start of Test End of Test

Time (Hours)
Pressure Kg/cm2 or Bar (G)

Yes N/A
RECORDING INST. / PRESSURE GAUGE : CHECK CALIBRATION

TEST RESULT : ACCEPTED / REJECTED

Yes N/A
ATTACHED :

Remarks :

Actual Pressure = ………… Kg/cm2 or Bar

holding time

Test Pressure = ………………Kg/cm2 or Bar

Design Pressure = ………… Kg/cm2 or Bar

SUBCONTRACTOR CONTRACTOR OWNER

Print Name

Signature

Date
 FORM NO. QI - L.07.01
PEMBANGUNAN FASILITAS PENGOLAHAN SAMPAH LANDFILL MINING
DAN RDF PLANT (RANCANG DAN BANGUN)

PIPING PRESSURE TEST REPORT

PROJECT TITLE : TEST FLUID :

JOB. NO. : HOLDING TIME :
Date Test . : TEST RESULT : Accepted / Rejected
Test Package No . :

Run-of-Line Bar g Witnessed by

NO. P&ID NO Line Number REMARKS
From To Design Test Req'd Actual CONT. OWNER

Signature : Signature : Signature :

SUBCONTRACTOR CONTRACTOR OWNER

Date : Date : Date :

 Form No.: Date :
PEMBANGUNAN FASILITAS
PENGOLAHAN SAMPAH LANDFILL QI- L .08
MINING DAN RDF PLANT (RANCANG Report No: Page
of
DAN BANGUN)
Subject : Piping Works Installation Check List (Above Ground Piping) Project No :

Project : Location :
P & ID Dwg. No. : Isometric Dwg. No. :

RESULT
NO ITEM TO CHECK DATE & SIGN REMARKS
YES N/A

1 PRE-FABRICATION
a. Material
b. WPS & PQR
c. Welder
d. Preparation to Weld
e. Inspection of Welds / Visual
f. Radiography Interpretation

2 INSTALLATION
a. Support, pipe rack
b. W.P.S
c. Welder
d. Preparation to Weld
e. Inspection of Welds
f. Radiography Interpretation
g. Hydrostatic Test
h. Surface Preparation
I. Painting
j. Insulation

Comment :

Prepared By: Checked By : Approved By :

SUBCONTRACTOR CONTRACTOR OWNER

 Form No.: Date :
PEMBANGUNAN FASILITAS
PENGOLAHAN SAMPAH LANDFILL QI- L .09
MINING DAN RDF PLANT (RANCANG Report No: Page
of
DAN BANGUN)
Subject : Piping Works Installation Check List (Under Ground Piping) Project No :
Project : Location :
P & ID Dwg. No. : Isometric Dwg. No. :

RESULT DATE &

NO ITEM TO CHECK REMARKS
YES N/A SIGN

1 FABRICATION
a. Material Specification
b. WPS & PQR
c. Welder
d. Preparation to Weld
e. Inspection of Welds / Visual
f. Radiography

2 INSTALLATION
a. Trench & Bed Condition
b. WPS & PQR
c. Welder
d. Preparation to Weld
e. Inspection of Welds
f. Radiography
g. Hydrostatic Test
h. Surface Preparation
I. Outer Tape Wrap
j. Holiday Test
k. Backfilling

Comment :

Prepared By: Checked By : Approved By :

SUBCONTRACTOR CONTRACTOR OWNER

 Date :
PEMBANGUNAN FASILITAS PENGOLAHAN Ql-L.10
SAMPAH LANDFILL MINING DAN RDF
PLANT (RANCANG DAN BANGUN) Report No.
Page : of

Subject : PIPING REINSTATEMENT Project no :

SYSTEM : AREA :
P&I D DRAWING NO. : ISOMETRIC DWG NO. :
REFERENCE NO. : DOCUMENT NO. :

RESULT
No. INSPECTION/TEST ITEM SIGNATURE DATE REMARKS
YES N/A
Check that flushing have been satisfactory
1
completed and recorded
Check that all pipe cleaning and pickling has been
2 satisfactory completed and recorded

3 Drying/drainage of lines completed and accepted

Check that correct bolts and gaskets are installed

4 at all mechanical joints

Check that all vents and drains comply with piping

5 specification

Check that all process blinds and spades have

6 been correctly installed as indicated on the P&ID

Check that spectacle blinds are in the correct

7 'flow' position

Check that control valves have been installed in

8 the correct 'flow' position

Check that specified block valves have been

9 locking devices correctly installed

Check that relief valves have been correctly

10 installed

Check that all thermo wells have been correctly

11 installed

Check that restriction and orifice plates have been

12 correctly installed

Check that all pump suction strainers have been

13 correctly installed

Check for correct flow through filters and

14 strainers, traps and all valves

Remarks :

Prepared by Checked by Approved by

SUBCONTRACTOR CONTRACTOR OWNER
Print Name
Signature
Date
`
 Date :
QI-L.11
RELOKASI FLARE BPP II & NEW FLARE HCC RU V
Report No. : Page :
PERTAMINA BALIKPAPAN

Project Title: RELOKASI FLARE BPP II & NEW FLARE HCC

Job No. :
SUBJECT : MECHANICAL COMPLETION OF PIPING WORK

SYSTEM : LINE NO. :

ORIGIN : TERMINATION :
TEST CIRCUIT : TEST PRESSURE :

RESULT
TEST / INSPECTION ITEMS YES N/A

1. All pipe work and standard pipe support are installed.

2. Spring hangers and special pipe supports installed.

3. Bolts and Gaskets are installed according to specification.

4. Valves are correct to specification.

5. Lines are tested and flushed.

6. All temporary gasket are replaced by service gaskets

Test Package No.:

6. Punch list category 'A & B' items completed.

Punch List No.:

Signature, Signature, Signature,

Subcontractor Contractor Owner

Date Date Date
 Date
PEMBANGUNAN FASILITAS QI-L.12
PENGOLAHAN SAMPAH LANDFILL
MINING DAN RDF PLANT (RANCANG Report No. Page :
DAN BANGUN)

Project Title:

Subject : MAGNETIC PARTICLE EXAMINATION REPORT Job No.:

Line No. :

Spool No. :

Applicable code Stage of examined

As Welded After Hydro. Test

Material Before/After P.W.H.T Others
Surface Preparation Grinding Machine Others

Magnetizing Technique
Water Magnetizing Current Amp

Prod Spacing
Magnetizing

Method Lifting Power Ib & kg

Yoke Pole Spacing

Directing of Magnetizing

Medium Dry Wet Fluorescent

Location Examined

(Isometric and Joint No.)

Total Welds are examined:

Judgement Satisfactory Attachment Report

Unsatisfactory

Signature Signature Signature

Subcontractor Contractor Owner

Date:_____________ Date:________________ Date:_____________
 Date
PEMBANGUNAN FASILITAS QI-L.13
PENGOLAHAN SAMPAH LANDFILL
MINING DAN RDF PLANT (RANCANG Report No. Page :
DAN BANGUN)

Project Title:

Subject : LIQUID PENETRANT EXAMINATION REPORT Job No.:

Line No. :

Spool No. :

Applicable code Stage of examined

As Welded After Hydro. Test

Material Before/After P.W.H.T Others
Surface Preparation Grinding Machine Others

Type Color Contrast Fluorescent

Penetrant Application Brushing Spraying

Temperature Penetrant Time Minutes

Water-Washable Penetrants
Dry Developer
Removal Post-Emulsifying Penetrants Developing

Solven-Removable Penetrants Wet Developer

Location Examined

(Isometric and Joint No.)

Total Welds are examined:

Judgement Satisfactory Attachment Report

Unsatisfactory

Signature Signature Signature

Subcontractor Contractor Owner

Date:_____________ Date:________________ Date:_____________
 Date
PEMBANGUNAN FASILITAS QI-L.14
PENGOLAHAN SAMPAH LANDFILL
MINING DAN RDF PLANT (RANCANG Report No. Page :
DAN BANGUN)

Project Title:

Subject : RADIOGRAPHIC EXAMINATION REPORT Job No.:

Line No. :

Spool No. :

Applicable code Stage of examination

As Welded After Hydro. Test

Material & Thickness Before/After P.W.H.T Others
Degree of Examination Spot % Full

Source Film
Equipment Equipment No. Film Mask Technique

Focus Size Condition Intensifyng Screen

Exposure Tube Voltage Exposure Time

Conditions Tube Amperage kVP Source to Film Distance cm

Dose mA Penetrameter mm

Location Examined (Isometric Drawing No. and Joint No.) Total Welds are examined:

Signature Signature Signature

Subcontractor Contractor Owner

Date:_____________ Date:________________ Date:_____________
 Date
QI-L.15
RELOKASI FLARE BPP II & NEW FLARE
HCC RU V PERTAMINA BALIKPAPAN Report No. Page :

Project Title: RELOKASI FLARE BPP II & NEW FLARE HCC

Subject : ULTRASONIC EXAMINATION REPORT Job No.:

Line No. :

Spool No. :

Applicable code Stage of examined

As Welded After Hydro. Test

Material Before/After P.W.H.T Others
Method Straight Beam Angle Beam

Type of Equipment

Couplant Water Motor CMC Glycerine

Detecting Direction Axial Radial Circumferential Others

Type Frequency Mhz

Transducer Normal Straight

Angle 45° Deg 60° Deg 60° Deg

Standard Test Block

Sensitivity Setting Sensitivity

Scaning

Location Examined

(Isometric and Joint No.)

Total Welds are examined:

Judgement Satisfactory Attachment Report

Unsatisfactory

Signature Signature Signature

Subcontractor Contractor Owner

Date:_____________ Date:________________ Date:_____________
 QI - L.16
RELOKASI FLARE BPP II & NEW FLARE HCC RU V AREA :
PERTAMINA BALIKPAPAN
DATE :

SUBJECT : POST WELD HEAT TREATMENT REPORT

LINE NO REPORT NO

ISO/DRG NO MATERIAL GRADE

WELD NOS.
PLATE PIPE
PIPING CLASS CHART NO LENGTH DIA.
THK. THK.
SPECIFICATION

EQUIPMENT

DESCRIPTION

DATE OF
RECORDER No. CALIBRATION

RESULTS (RECORDER CHARTS TO BE ATTACHED)

UNRESTRICTED RATE OF RISE TO RESTRICTED RATE OF RISE OF

.............. �C .............. �C PER HOUR

SOAK TEMPERATURE SOAK TIME

.............. �C CHART SPEED mm Hr .............. HOUR

RESTRICTED RATE OF FALL OF UNRESTRICTED RATE OF FALL FROM

.............. �C PER HOUR .............. �C

RESTRICTIONS/COMMENTS SKETCH OF THERMOCOUPLE POSITION

COMPLETED BY SUBCONTRACTOR CONTRACTOR OWNER

SIGNATURE

NAME

DATE
 Date :
RELOKASI FLARE BPP II & NEW QI-L.17 Page :
FLARE HCC RU V PERTAMINA
BALIKPAPAN Report No. Project No. :

SUBJECT : HARDNESS TEST RECORD

Spool /Line/ Weld :

Location :

REQUEST FOR HARDNESS TESTING

Date

The lines noted below have been visually examined and are now ready for hardness testing.
Scaffolding is required and has been erected.

These lines will be postweld heat treated and will require testing before relocating equipment.

SUPERVISOR

HARDNESS TESTING
Location of point measurement:

The line noted above has been Hardness Tested and was ( not ) acceptable.

Weld Number and Hardness Result.

LOCATION HB REQUIREMENT HB WELDMENT HB H.A.Z. HB BASE MATERIAL

NDT EXAMINER

Signature, Signature, Signature,

SUBCONTRACTOR CONTRACTOR OWNER

Date : Date : Date :
 Date :
PEMBANGUNAN FASILITAS PENGOLAHAN QI - N.01
SAMPAH LANDFILL MINING DAN RDF PLANT Doc No. : Page :
(RANCANG DAN BANGUN) of

Subject : PAINTING INSPECTION REPORT Project No. :

Project : Reference Drawing:

Owner :
Equipment / Line No. :
Location :

Repair (Touch-up) parts

Surface Preparation :
Material :
Dry Film Thickness :
Coat No. :
Methode :

General Parts
Surface Preparation :
Painting System :
Material Spec. :
Primer / 1st Coat Intermediate/2nd Coat Finish/Top Coat
Product No.
Product Name
Paint Type
Color / Musel No.
Batch No.
Methode
Dry Film Thickness
Total Dry Film Thickness

Appearance :

Actual Dry Film Thickness : See QI-N.01.01 as attached

Remarks :

Test Result

Acceptable

Not Acceptance

Signature Signature Signature

SUBCONTRACTOR CONTRACTOR OWNER

Date : Date : Date :
 Date
PEMBANGUNAN FASILITAS PENGOLAHAN SAMPAH LANDFILL MINING DAN RDF PLANT QI-N.01.01
(RANCANG DAN BANGUN) Doc. No Page

Subject : PAINTING DRY FILM THICKNESS Project No. :

DRY FILM THICKNESS (μm) RESULT

NO EQUIPMENT / LINE NO. DRAWING AREA P. SYS REMARKS
Primer Coat 2nd Coat Finish Coat ACC REP

SUBCONTRACTOR CONTRACTOR OWNER

Print Name

Signature

Date
 Date
RELOKASI FLARE BPP II & NEW QI - N.02
FLARE HCC RU V PERTAMINA
Doc. No. Page
BALIKPAPAN
Subject : INSULATION INSPECTION RECORD Project No :
Project : RELOKASI FLARE BPP II & NEW FLARE HCC Location :
Equipment No. : Reference Drawing :

RESULT
NO ITEM TO CHECK DATE & SIGN REMARKS
YES N/A

MATERIALS
1 Materials specification conforms to the requirements.
2 Material thickness as specified or insulation system
3 Fasteners conform to the specification requirements.

APPLICATION
1 Piping or Equipment system released for insulation and
accepted.
2 Surface preparation checked.
3 Primer specified and accepted.
4 Insulation distance and / or support rings correctly
instlalled.
5 All gaps filled with insulating cement.
6 Spacing and fitting of clips and pins per specification.
7 Jacketing installed and sealed per specification.
8 Banding and screws installed per specification.
9 Insulation expansion joints correctly installed.
10 Completed work is acceptable in terms of existing
specification and standard.

Remarks :

SUBCONTRACTOR CONTRACTOR OWNER

Print Name
Signature
Date
 FORM NO. QI-N.02.01
PIPING INSULATION INSPECTION REPORT
Date :
Owner : PT PERTAMINA Reference No. :
Document No. :
Project Title : RELOKASI FLARE BPP II & NEW FLARE HCC

Name of equipment
and Identification No. :

Insulation Spec. Insulation

Surface Insulation Thickness Vapor Metal Final Visual Remarks
Line No. Cleaning Material and No. of Barrier Jacketing Inspection
Layers

Signature : Signature : Signature :

Prepared by Checked by Approved by

SUBCONTRACTOR CONTRACTOR OWNER

Date Date Date
 FORM NO. QI-N.03
PEMBANGUNAN FASILITAS PENGOLAHAN
REPORT NO :
SAMPAH LANDFILL MINING DAN RDF
DATE :
PLANT (RANCANG DAN BANGUN)
PAGE :

Subject : WRAPPING CHECK LIST Project no :

SYSTEM : AREA :
P&I D DRAWING NO. : ISOMETRIC DWG NO. :

RESULT
No. INSPECTION/TEST ITEM SIGNATURE DATE REMARKS
YES N/A
1. Check material accepted

2. Surface manual cleaning

3. Check aplication coating primer

4. Check inner wrap

5. Check outer wrap

6. Check Overlap

7. Check Visual

8. Holiday detector test

Remarks :

SUBCONTRACTOR CONTRACTOR OWNER

Print Name

Signature

Date
`
 Date :
PEMBANGUNAN FASILITAS PENGOLAHAN
SAMPAH LANDFILL MINING DAN RDF PLANT
(RANCANG DAN BANGUN)
QI-N.03.01 Page :

Subject : WRAPPING CHECK & HOLIDAY TEST Doc No. :

Owner : Diameter Pipe :

Project : Holiday Kv Used :
Location : Surface Preparation :
Line No. : Machine Type :

Inspection
No No. Joint Surface Preparation Holiday Test Remark
Visual Check
Check Kv Result

Remarks:

Signature Signature Signature

SUBCONTRACTOR CONTRACTOR OWNER

Date : Date : : Date :
 PEMBANGUNAN FASILITAS PENGOLAHAN SAMPAH
LANDFILL MINING DAN RDF PLANT (RANCANG DAN
BANGUN)

TEST PACKAGE INDEX

INDEX OF CONTENT :
YES N/Y N/A

1. APPLICATION FOR INSPECTION

2. TEST BLOCK DIAGRAM & INDEX LIST

3. SPOOL DRAWING & LIST

4. WELD TRAVEL SHEET

5. SUMMARY NDT

6. PRESSURE TEST RECORD

7. CERTIFICATE CALIBRATION OF PRESSURE GAUGE

8. LINE CHECK REPORT

9. PNEUMATIC TEST REPORT OF PAD

10. PUNCHLIST REPORT

PREPARED BY, REVIEWED BY, APPROVED BY:

CONTRACTOR OWNER
SUBCONTRACTOR

(…………………...……..) (…………………………………..) (…………………………………..)

 PUNCH LIST REPORT

Project Title : RELOKASI FLARE BPP II & NEW FLARE HCC Unit / Facility : Test Package No. :
JOB No. : Area :

Piping Mechanical Instrument Electrical Civil & Structure Others

Punch List Category Accepted

Item Date
Punch List Description Approved Target Date SUB Remarks
No. A or B Cleared CONTRACTOR
CONTRACTOR OWNER
CONTRACTOR OWNER

COMPLETED SUBCONTRACTOR CONTRACTOR OWNER

PRINT NAME

SIGNATURE
Note Category Description :
SIGNATURE
A fter : Item shall be corrected After Mechanical Completion
B efore : Item shall be corrected before Mechanical Completion
DATE