Manyar Smelter Project

SITE VISIT REQUIREMENTS FORM

COMPLETED BY TRAVELER

BASIC INFORMATION
Traveler Name: Ahmad Zaelani Title: Inspector

Company: PT Jotun Contact Number:

+62 85230049465
Passport No.: 3525101607740005 Previous Site Visit:

Site Entry Date: 03th April 2024 Site Exit Date: 04th, April 2024

Purpose of the trip: Goemembrane Spark testing

(Please describe)

AGENDA – Please also attach the meeting agenda

DATE (ddmmyy) TIME (24hr) BRIEF DESCRIPTION HOST NAME & CONTACT INFO LOCATION
04th April – 05th, April 08.00 – finish Goe Membrane Spark Testing PT Petrosea - Gresik

SITE LUNCH REQUEST

Point of Contact POC Location of Name of Date Time Location of
(POC) Phone Number Visit Admin Assistant Required Required Lunch Delivery

Dietary Requirements:
(Please specify if any)

PPE REQUEST AND SAFETY INDUCTION

PPE required

Safety Shoes size:

Any previous site

Is safety induction required induction National or Expat Site tour or Point View only

Indonesia

Note:
• Safety induction is required for visitor who will visit to field or site area
• Please attach some required documents:
1. Identity Card
2. Vaccine certificate with minimum 2nd dose
Item no. 2 and 3 refer to Site Covid-19 Health Protocol (HSE-PRO-9004 Rev.11)
• Please bring your own PPE (Long sleeve c/w safety vest, safety helmet, safety glasses, safety shoes, mask 3ply)

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 Manyar Smelter Project
SITE VISIT REQUIREMENTS FORM

Z:\\phxntoncfile\sharedir\CVPUE\FCX\forms\PA\AD\ Form No.: CVPUE-AD003

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 Manyar Smelter Project
SITE VISIT REQUIREMENTS FORM

Note :
Working on the Project Site 7(seven) days or less requires the worker to provide a Health Certificate from
their doctor prior to mobilization

Z:\\phxntoncfile\sharedir\CVPUE\FCX\forms\PA\AD\ Form No.: CVPUE-AD003

Updated on 17 Apr 2013 Page 3 of 2