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PROYEK CUSTOMER ATTACHMENT
AREA CILEGON - CV MUTIARA ELASTICINDO
o
Request No- i 001
CA Area Cilegon Date : 28'Dec-28

: Wildan Jalaludin - Site Co - PGN PGAS'S PIC : Ardhiansyah " Site Manager
I
: Benhur Wahyudin - Prciect Manager . PGN Solution HP : 0813 6652 2245

NO ACTIVITIES TIME LOCATION/KP TYPE OF REPORT TYPE OF INSPECT REMARKS Prc

On Board QC, HSE,

Joshua
I Progress Control. 0800-17.00 Office PGN Tanqerang MOM CoorCinatlon Continue
(0812 9'161 0654)
Traceabilily

Coordiflation With PU Joshua

2 08.00 - 17.00 PU Kabupaten Serang BA Report Continue
Serang (0812 9161 06s4)

of lnspection : 28-Ds-20
08.00 - 17.00
t:] Joint Suruey

il Materjal Veairlcation/Preparation

tf
PU
Witnessing of Tesiing

tt Release Hold Point

m Oflly thts Repori

f Dra*'n9

tr lnspection Report '-^

Lll buruey xepon
il Visual for NDT

ll Punch List
n Testing Report
f, H""uv Equipmeni Report
t_l Final lnspection

E Equipment and Tools lrspection

RESULTICONCLUSION (by Employer/Engineer):

Test / lnspection Result Satisfactory

E No Objection & Proceed for Next Work

B Tesl I lnspection R6sult Unsatisfactory

E No ObjeCion with Remarks

C Requires Re-Work and or Re-Test

tr
!f result is B. C or E, piease put the note belowl

Prepared by Reviewed by
PT. PGAS Solurion PT, Perusahaan Gas Nagam Tbk.

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.JxuuA s. a,r\
Oate 28-Dec-20 Oate ,4
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$0LuT10N PROYEK CUSTOMER ATTACHMENT
AREA CILEGON . CV MUTIARA ELASTICINDO
o
CA Area Cilegon Date 29-Dec-20

: Wildan Jalaludin - Site Co - PGN PGJAS'S PIC i Ardhiansyah - Site Manager

: Eenhur Wahyudin . Proiect Manager - PGN Solutaon HP : 0813 6652 2245

NO ACTIVITIES TIME LOCATION/KP TYPE OF REPORT TYPE OF INSPECT REMARKS Plc

Joshua
1 Join Suruey 08 00 - 17.00 SPBG Serang Report Continue
(0812 9161 0654)

of hspection 2g-Dec-20 E Joint Suryey

08.00 - 17.00

n lvlate.ial Verilicalion/Preparation

fl
SPBG Serana,
Witnessing of Tesiing

T Releese Hold Point

tr only this Report fl orawins

t_l Visualfor NDT

I lnspection Report
fl suruev neport

E Punch List

I Testing Report
I HeaYy Equipment Report

E Final lnspeclicn

E Equipment and Tcols Inspection

T/CONCLUSION (by Employer/Enginaer):

Test / lnspection Result Satisfactory

tr No Objection & Proreed for Next Work

B Test / lnspection Rasutt Unsatisfactory E Nc Objeetion with Remarks

c Requires Re-Woft and or Re-Test tr

result is B C cr E, piease put the note below:

Prepared by Review€d by
PT- PGAS Solution PT. Perusahaan Gas Negarc Tbk-

Jffiet
rlos+rua
Date 29-Dec-2$
I Oate ?-t1
 ii;i;ii i SOLUTION PROYEK CUSTOMER ATTACHMENT
AREA CILEGON - CV MUTIARA ELASTICINDO
o
Pil
PT.
: 003
CA Area Cilegon Date i 5.Jan-21

i Wildan Jalaludin , Site Co - PCN PGAS'S PIC Ardhiansyah - Site Managsr

: BenhurWahvudin - Proiect Manager " pGN Solution HP : 0813 6652 2245

NO ACTIVITIES TIME LOCATION/KP TYPE OF REPORT TYPE OF INSPECT REMARKS Ptc

Survey Direksi Keet and Direksi Keet Serang - Jl

I I '1.00 - 17.00 BA Report Joshua
Temporary Stcck Pile Kaserangan Pengampelan Conlinue
(0812 9161 0554)

of lrepection 5-Jan-21
1'1.00 - 17.00
r Joinl Suryey

E [raterial Veritication/Preparation

t:] Witnessing of Testing

i:l Release Hold Point

U only this Report lTl orawins

tt Visuai for NDT
n lnspection Report
f| Suruey Report

f, Testing Report Heavy Equipment Reporl

E Punch List
tr
t] Final inspectlon

[] Equipmenl and Tools lnspection

TICONCLUSION (by EmptoyertEngin*r):

E Test / lnspection Resu,t Satisfactory

E No Objection & Proceed for Next Work

T:
L3 Test I Inspection Result Unsatisfactory
H l.l0 Objection wth Remarks

I
^l
L:] Requires Re-\lvod( and or Re-Test
E
result is B C or E, the note below:

Pr€pared by
ReYiewed t y
PT. PG,A.S Solution
PT. Perusabaan Gas Negara Tbk.

ffir d"r*lu o. s.
Date 5-Jatr-21
Oatc
 -
j "i i.:l i.l SOLUIION PROYEK CUSTOMER ATTACHMENT o
: ,., ll AREA CILEGON' CV MUTIARA ELASTTCINDO
Fff
Request No. 004
CA Area Cilegon Date 9Jan-21

i Wildan Jalaludin - Site Co . PGN PGAS'S PIC : Ardhiansyah - Site Manager

: Benhur Wahyudin " Proiect Manager - PGN Solution HP : 0813 6652 2245

NO ACNVITTES TIME LOCATIONIKP TYPE OF REPORT TYPE OF INSPECT REMARKS Prc

Direksi Keet Serang - Jl gA Joshua

1 Mobilisalion Equipment 08.00 - 17.00 Report Contlnue
Kaserangan Pengampelan (0812 S161 0654)

ot lnspection 9-Jan-2'l E Joint Suruey

D
o&.00 - 17.00
Malerial Verm€tionlPreparation

t:] Witnessing of Testing

n Release Hold Point

tr Only thls Repo* nDrawing

tl Visuai ior NDT

n lnspection Report f] Suruev neport

tl Punch List

tl Testing Report l-l H""uy Equipment Repoil

tl Final lnspeclicn

t:] Equrpment and Tools lnspecticn

RESULT/CONCLUSION (by Employer/Engineer):

Test / lnspection Result Satisfactory D No Objectioo & Pro@ed for Next Work

Test / Inspection Result Unsatisfactory E No Ofljection with Remarks

C Requires Re-Work and or Re-Test F

result is the note belcw:

Prepared by Reviewed by

PT. PGAS Solution PT, Perusahaan Gas Negam Tbk.

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Oate $Jan-21 Oate o
 -

FHIi
s0LunoN PROYEK CUSTOMER ATTA.CHMENT
AREA CILEGON - CV MUTIARA ELA.STICINDO
o
Negare Request No. ; 005
CA Area Cilegon Date | 20-Jan-21

; Wildan Jalaludin - Site Co - PGN PGAS'S PIC : Ardhiansyah - Site Manager

I Benhur Wahyudin - Proiect Manager - PGN Solution HP : 0813 6652 2245

NO ACTIVITIES TIME LOCATIONIKP TYPE OF REPORT TYPE OF INSPECT REMARKS Prc

Joshua
I Penentiran -fitik Tesi Pit 08.00 - 17.00 Jl. Kaserangan Pengampelan BA Report Coniinue
(0812 S161 0654)

Oireksi Keet Serang - Jl. Joshua

2 Salety lnduction 08.00 - 17.00 BA Report Continue
Kaserangan Peogampelan (0812 9161 0654)

of lnspeclioB 20Jan-21
08-00 - t7.oo
ul Joint Survey

[Iaterial Verifi cation/Preparation

Wiinessiflg oi Testing

t:] Release Hold Poinl

Only this Report

I ora*ins
t_l Visual ior NDT
lnspection Repori
fl Suruev Report
Punch List
Testing Report
fI Heavy Equipment Report
Final lnspeciion

Equipment and Tools lnspecticn

RESULT/CONCLUSION (by Employer/Engineer):

Tesi / Inspection Result Saiisfactory D No Objection & Proceed for Next Work

B Test I inspection Result Unsatisfactory E No Objection wilh Remarks

c Requires Re-Woak and 0r Re-Test a

lf result is B, C or E, please pui the note below:

Prepared by ReYiewed by
PT. PGAS Solution PT. Perusahaan Gas Negara Tbk.

M} tOS(too I A,lh
,

Eate 20Jan-21 Date ))

 -

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SOLUNON PROYEK CUSTOMER ATTACHMENT
AREA CILEGON - CV MUTIARA ELASTICINDO
o
P"*
CA Area Cilegon Date 224an-21

: Wildan Jalaludin - Site Co - PGN PGAS'S PIC : Ardhiansyah - Site Manager

: Benhur Wahyudin - Proiecl Manager - PGN Solution HP : 0813 6652 2245

NO ACTMITIES TIME LOCATION/KP TYPE OF REPORT TYPE OF INSPECT REMARKS Plc

Saiety Jnductlonl Direksi Keet Serang - Jl. Joshua

1 08.00 - 17.00 BA Report Contlnue
HSSE Pass Kaserangan Pengampelan (0812 9161 0654)

of lnspeation 22.lan-21 E Joinl Suruey

08.00 - 17.00

r Material VerifictionlPreparation
JI

t: Wit(essiffg of Tesiing

t:] Release Hold Point

E Only this Report [*l orawing

n lnspeclion Repor!
[} Suruev Report
il Visuat for NDT

n I Punch Lisl
Testing Report
Ll Heavy tqurpment Heporl

x Final lnspect,on

t:] Equipment and Tools lnspecticn

RESULTICONCLUSION (by Employer/Engineer):

Test,/ lnspection Resuli Satisfactory

E No Objection & P.oceed for Nexl Work

B Test / lnspection Result Unsatisfactory

tr No Obj€tion wilh Reilarks

Requlres R6-Work and or Re-Test

E
lf result is B, C or E, please put the note below

Prepared by Reviewed by

q\){
PT. PGAS Solution PT. Perusahaan Ga3 Negam Tbk.

Nr*t'
{os*uq l' 4. liAar, 1."r.^
Oate 22-Jan-2'l Dare otb /ol/ La
 i1,i'iTi sLUno[l PROYEK CUSTOMER ATTACHMENT
AREA CILEGON . CV MUTIARA ELASTICINDO
:

PT. Request : 007

CA Area Cilegon Date | 25-Jan-21

: Wildan Jalaludin - Sits Go 'PGN PGAS'S PIC : Ardhiansyah - Site Manager

: Benhur wahyudin - Prciect Manager - PGN Solution HP : 0813 6652 2245

NO ACTIVITIES TIME LOCATION/KP TYPE OF REPORT TYPE OF INSPECT REMARKS Ptc

lnspeksi Alat Angkat & Joshua

08.00 - 17.00 Cilegon & Tanjung Priok BA Report Coniin!e
1
Alat Angkut (0812 9161 0654)

of lnspection 26"Jan-21 tI Joint Survey

08"00 - 17.00
n Matetral VerificationlPreparation

t:] Witnessing oi Testing

t:] Release Hold Point

II Ooiy this Report f-l orawins

D Visual for NDT

tr lnspection Report fl suruey neport

E Punch List

tr Testing Repori ITI nu"uy Equipment Report

n Final lnspection

t:] Equipment and Tools lnspection

RESULT/CONCLUSION (by Employer/Engineer):

Test / lnspectlon Result Satisfactory E No Oblection & Proceed for Next Work

B Test I tnsp*tion Result Unsatisfactory tr No Ob.iection Y{ith Remarks

C Requires Re-Work and or Re-Tes1 tr

result is B, C or E p{ease put ihe ncte below:

Prepared by Reviewed by

PT. PGAS Solution PT, Perusahaan Gas Negara Tbk.

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Date 25-Jan-21 Oate e
 -
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ii'r''! $0tU1101'l
I
PROYEK CUSTOMER ATTACHMENT
AREA CILEGON - CV MUTIARA ELASTICTNDO
o
P.8F
Request No. : 008
CA Area Cilegon Date : 264an-2'l

: Wildan Jalaludin - Site Co - PGN PGAS'S PIC : Ardhiansyah - Site Manager

: Benhur Wahyudin - Proiect Manager - PGN Solutioo HP : 0813 6652 2245

NO ACTIV}TIES TIME LOCATIONIKP TYPE OF REPORT TYPE OF INSPECT REMARKS Plc

Joshua
I lnspeksi Crane 08 00 - '17 00 Cilegon BA Report Continue
(0812 9161 0654)

lnspection 27.Jan-21 [I Joint Suruey

08.00 - 17.00

Cileooil.
n t\,4aterial Veritl€tionlPreparation

fI Witnessing cf Testing

ll Release Hold Poini

E Only this Report

f] orawins
ff Visual for NDT

m
n
lnspstion Report

Testing Report
Dl
El
Suruey xepon

Heavy Equipment Report

n Punch Lisi

fl Frnal lnspecticn

[:] Equlpmert and Tqcls lnspection

RESULT/CONCLUSION (by Employer/Enqineerl:

Test / lnspection Result Satjsfactory D No Objectlon & Proceed for Next Work

tr Test ,/ lnspeclion Resull Unsatisfactory E No Objetion with Remarks

Requires Re-Work and or Re-Test F

lf result is B C cr E. please pul the note lleloy/l

Prepared by Reviewed by
PT. PGAS Solwion PT. Perusahaan Gas Negara Tbk.

)N,6t (,
lPl$un q.!l
Oate 27-.lan-21 DatB
 -

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$OLUTION PROYEK CUSTOMER ATTACHMENT
AREA CILEGON, CV MUTIARA ELASTICINDO
e
pgn
PT- Perushaan Negara Tbk. Reque3t No. 009
CA Area Cilegon Date 28-Jan.21

: Wildan Jalaludin - Site Co - PGN PGAS'S PIC : Ardhiansyah - Site Manager

: Benhur Wahyudin - Prcject Manager - PGN Solution HP : 4A1365522245

NO ACTIVITIES TIME LOCATION/KP TYPE OF REPORT TYPE OF INSPECT REMARKS Ptc

Joshua
1 Mobilisasi Pipa 08.00 - Selesai Surya Cipta - Serang BA Report Continue
(0812 9161 0654)

Date ot lnspection 29-Jan-21

08.00 - Selesai
E Joint Suruey

Place Surva Ciota - Serano.

E il,rlaterial VerificationlPreparation

t:] \rditnessing ai Testing

t:] Release Hold Point

T,:-l Orly this Report {-l orawing

t---J

E lnspeciion Report
f| Suruey Report
tl Visual for NOT

tl Testing Repori
U Heavy Equipment Report
E Punch List

tf Final lnspmtion

tl Equipment and Tools lnspection

RESULT/CONCLUSION (by Employer/Engineer):

E Test / lnspectaon Result Satisfactory D No Oblection & Proceed for Nexi Work

tr Test I lnspecticn Result Unsatisfactory [-Fl i'to ooi""tton *ith Remafts

E R-.quires Re-Work and or Re-Test F

It result is B, C or E, please pui the note below:

Prepired by Reviewed by
PT, Perusahaan Gas Negam Tbk.

xd,(
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Date 29Jan-21 oare bO r>1
 -
i"i*-:'r sotufloN
I'i::" PROYEK CUSTOMER ATT,ACHMENT
AREA CILEGON . CV MUTIARA ELASTICINDO

Requ6t No, : 010

CA Area Cilegon Date : 29-Jan-21

Wildan Jalaludin - Site Co - PGN PGAS'S PIC : Ardhiansyah - Site Manager

Benhur Wahyudin - Prciect Manager - PGN Solution HP : 0813 6652 2245

NO ACTIVITIES TIME LOCATIONIKP TYPE OF REPORT TYPE OF INSPECT REMARKS Ptc

Gudang Surya Cipta .loshua

1 Loading Unloadinh Pipa 17.00-00.00 BA Report Continue
Karawang - Serang (0812 9161 0654)

of lnspection 29-Jan"21 r-i--i Joint Survey

17.00-00"00
E Material Verif icalion/Preparation

T'.l Witnessing of TestinE

t:] Release Hold Point

tr onty this Report f orawing

t:] Visual for NDT

E
L__l
lnspection Reporl

estrng Hepon
fl
l-
suruey Report

Lu_l Heavy tqurPrnent HePon

T Punch List

E
i

Final Inspection

n Equipment and Tools Inspection

RESULT/CONCLUSION (by Employer/Engineer):

Test / lnspectioo Result Satisfactory E No Objection & Promed for Next Work

B Test / lnspection Result Unsalisfacto.y E No Cbjection witi. Remarks

C Requires Re-Wcrk and or Re-Test E

lf iesult is I, C or E, please put the note below:

Prepared by Reviewed by

4,,
PT. PGAS Solution PT. Perusahaan Gas Negara Tbk.

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-\o(UuP S' A' fu[, 1^r-^
Oate 30-Jan-2, oare ol f O>l t\
 -

FI]ii
SOLUTION PROYEK CUSTOMER ATTACHMENT
AREA CILEGON. CV MUTIARA ELASTICINDO
o,:
CA Area Cilegon Date 29"Jan-21

i Wildan Jalaludin - Site Co - PGN PGAS'S PIC : Ardhiansyah - Site Manager

; Benhur Wahyudin - Proiect Manager - PGN Solution HP :081366522245

NO ACTIVITIES TIME LOCATIONIKP TYPE OF REPORT TYPE OF INSPECT REMARKS Ptc

Joshua
1 Unloading Pipa 01.00 - 17.00 Temporary Stock Pile Serang BA Report Continue
(0812 9161 0654)

of lnspection 30Jan-21
01.00 - 17.00
til Joint Suiley

tI iviaterial Verification/Preparation

n Wtnessing of Tesiiflg

II Re,ease Hoid Point

ontyrhisRepori f]
t:
U orawins
Visual for NDT

[I lnspection Repod
fl suruer Reoon
tt Punch List
Testing Report Heavy Equipment Report
tr El
t_l Final lnspection

fl Equipment and Tools lnspeciicn

RESULTiCONCLUSION (by EmployerlEngineer):

Test / lnspection Result Sat,sfactory D No Objection & Proceed for Next Work

B Tesl / lnspection ,qesult Unsa$sfactory No Objection with Remarks

c Requires Re-Work and or Re-Test F

lf result is B C cr E, please put the nole belowl

Prepared by REYiewed by
PT. PGAS Solulion PT. Perusahaan Gas Neqara Tbk,

JK,$A
9.
{osH.tr
Date 30.ran-21 Dare d>t ^at
 q

1",."1 )"r'1 SOLUTMN PROYEK CUSTOMER ATTACHMENT o

AREA CILEGON - CV MUTIARA ELASTICINDO
P*
CA Ar& Cilegon Date 3lJan-21

Atn i Wildan Jalaludin - Site Co - PGN PGAS'S PIC : Ardhiansyah - Site Manager

: BenhurWahyudin - Proiect Manager - PGN Solution HP I 0813 6652 2245

NO ACTIVITIES TIME LOCATION/KP TYPE OF REPORT TYPE OF INSPECT REMARKS Ptc

Joshua
1 Gali Pit HDD 08.00 - 17.00 Jl Kaserangan - Pengampelan BA Report Continue
(0812 9161 0654)

lnspeksi HDD & Joshua

2. 08.00 - 17.00 Gudanq PT DGS Kebon Jeruk BA Report Continue
Excavator (0812 9161 0654)

of lrep$tion t-Feb-21 E Joint Suruey

08.00 - 17-00

n Material Veri{lcation/Preparaiion

E Wtnessing of Testing

E Release Hold Point

M
t:
T.,..l Only this Report orawing
t__l
Visuat for NDT

tr lftspection Repori
fl Suruey Repon

t:] Punch List

I Testing Report LfJ Heavy Equrpment Hepon

tl Final lnspection

fl Equipmeni and Tools lnspection

RESULT/CONCLUSION (by Employer/Engineer):

E Tesl / lnspection Result Salisfactory No Objection & Proceed for Next Work

rJ
t'-l Test / inspecticn Result Unsalisfa6tory [El ruo oqection with Remarks

r;1
L: Requires Re-Work and or Re-Test F

lf resuit is B, C cr E, please put the note beiowl

Preparsd by Reviewed by
PT. PGAS Sotution PT. Perusahaan Gas Negara Tbk.

)elr
..-\$Rus ,
tlate t-F€b-21 Oate
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SLUTION FROYEK CUSTOMER ATTACHMENT o
AREA CILEGON - CV MUTIARA ELASTICINDO

'a
nff
No. : 013
CA Area Cilegon Date : 2-Feb-21

i Waldan Jalaludin - Site Co - PGN PGAS'S PIC : Ardhiansyah - Site Manager

: Benhur Wahyudin - Proiect Manager - PGN Solution HP : 0813 6652 2245

NO ACTIVITIES TIME LOCATIONIKP TYPE OF REPORT TYPE OF INSPECT REMARKS Prc

lnspeksi Mesin HDD & Joshua

1 08 00 - 17.00 Gudang PT DGS Kebon Jeruk BA Repod Conlinue
Excavalor (0812 S161 0654)

of lnspectiail 3-Feb-21
trl Joint SuNey
0a-o0 - 17.00

n Material Verifl Gtion/Preparation

ul Witnessing of Testing

tf Relaase Hold Point

tr Only this Report l-J-l Drawins

il Visual for NDi
tr lnspection Report
fl Suruey Report

E Punch List

I Testing Repo{'t
E Hea\T Equipment Report

tl i:inal Inspection

t:] Equipment and Tools Inspection

RESULT/CONCLUSION (by Employer/Engineer):

Test / lnspection Result Satisfaciory

E No Objection & Pro@ed for Nexl Work

tr Test I lnspection Result Unsatisfactory

E No Objection with Remarks

tr Requires Re-Work and or Re-Test

E
lf result is B. C cr E, please put the note below:

Prepared by Reviewed by
PT. PGAS Solution PT. Perusahaan Gas Negam Tbk.

e,h( q.
JoL$uA
Date 3-Feb-21 Oate ,.r
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p.iiei{ r.
PROYEK CUSTOMER ATTACHMENT
AREA CILEGON . CV MUTIARA ELASTICTNDO
o
Request No. : 014
CA Ara Cilegon Date : 4-Feb-21

i Wildan Jalaludin - Site Co - PGN PGAS'A HC : Ardtiansyih - Site tlranager

: Benhur wahyudin - Project Manager - PGN Solution HP 08't3 6652 2245

NO ACNVITIES TIME LOCATION/KP TYPE OF REPORT TYPE OF INSPECT REMARKS Ptc

Joshua
I HSSE PASS 08.00 - 17 00 Direksi Keet Serang BA Repori Continue
(0812 9161 0654)

Joshua
2 POT o8.o0 - 17.00 Direksi Keel Serang BA Repod Continue
(0812 9161 0654)

&-Feb-21
og.ou - 11,u0
n Joifil Survey

m Material Vermcation/Preparation

tI r,4/itnessing of Testing

n Release Hold Point

tT Only triis Repsrt l-l orawins

u lnspection Repofi
[} Survey Report
t:] Visual for NDT

tt Punch List

tr Testing Report Ll Heavy fqurpmenr t(epofr

E Final lnspeciion

E Equipment and Tools Inspection

RESULT/CONCLUSION (by Employer/Engineer):

Test / lnspection Result Satisfactory D No Oblection & Proeed ior Nexi Work

B Test I lnspection Result Unsatisfactory E No Obleslion with Remarks

C Requires Re-lvork and or Re-Test tr

lf result is B C or E. please put the note below:

Prepared t y ReYiewed by

PT. PGAS $olution PT, Perusahaan Gas Negara Tbk.

AesL ,"
-b>ttt'tg'
Date 5-Feb-21 Date 2t
 -
l) !l!/ri:i l- i $0tuT1CIN PROYEK CUSTOMER ATTACHMENT
AREA CILEGON - CV MUTIARA ELASTIGINDO
a
P,Sn
Gas Negara Tbk. Request No, :015
CA Area Cilegon Date : 9-Feb-21

i Wildan Jalaludin - Site Co . PGN PGAS'SPIC : Ardhiansyah-SiteManaget

I Benhur Wahyudin - Proiect Manager - PGN Solution HP 08 t3 6652 2245

NO ACTIVITIES TIME LOCATIONIKP TYPE OF REPORT TYPE OF INSPECT REMARKS Prc

Joshua
I Mobilisasi Ball Valve 08.00 - 17.00 Gudang PGN Bogor BA Report Conlinue
(0812 9161 0654)

of lnspection 10-Feb-21
08.00 -17.00
tf Joint Survey

m Material Vorif i6ation/Preparation

Gudano PGN Boqor.
u W(nessirg of Testing

t:] Release Hold Point

tr Only this Report I-l Drawtns

tl Visual for NDT

E I
tl
Inspection Report Suruey Report
Punch List

T Testing Report l-l neauy Equipment Report

t:] Final lnspection

ll Equipment and Tools lnspeciion

(by Employer/Engineer):

Test / lnspection Result Satisfactory

E No Objection & Proceed ior Nexl Work

tr Tesi I Inspection Resull Unsatisfactory

H No Objeclion with Remarks

C Requires Re-Work and or Re-Tesi

tr
result is B, C cr E, the note below:

Prepared ty Reviewed by
PT- Perusahaan Gas Negara Ibk,

s;pr.
J:t{+uu >'
Date 10-Feb-21 Date
 -
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idi.li! q
PROYEK CUSTOMER ATTACHMENT
AREA CILEGON - CV MUTIARA ELASTICINDO
o
PT, Request No. ; 016
CA Ars Cilegon Date : 14-Feb-?1

r Wildan Jalaludin - Site CG - PGN PGAS'S PIC i Ardhiansyah - Site Manager

I Benhur Wahyudin - Proiect Manaqer - PGN Solution HP : 08'13 6652 2245

NO ACTIVITIES TIME LOCATIONIKP TYPE OF REPORT TYPE OF INSPECT REMARKS Ptc

Joshua
I SLrrvey Jaiur HDD 09 00 - 17.00 SPBG Serang BA Report Coniinue
(0812 9161 0654)

of tnspetion 15-Feb-21 E Joint Suruey

09.00 - 17.00

SPBG Seranq,
n Material Verifl cation/Prepaiation

TI witnessing ct Testing

i:l Release Hoid Point

u Orly this Report l-Tl orawins

ll Visualior NDT
n lnspection Report
f| suruey Report

E Punch List

n Testing Report L_] Heavy tqurpment Hepoft

tl Final inspection

t:] Equipment and Tools Inspeclion

RESULT/CONCLUSION (by Employer/Enqineer):

Test / lnspection Result Satisfa.tory

E No Objection & Pro€ed for Next Work

B Test I Inspection Resull Unsatisfactory

E Nc Objection o*ith Remarks

t-;:l
E Requires Re-Work and or RFTest L!

lf result is B, C or E, p,ease the noie below:

PrepaEd by Reviewed by
PT. PGAS Solution PT. Perusahaan Gas Negara Tbk.

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sotuIr0N PROYEK CUSTOMER ATTACHMENT
AREA CILEGON . CV MUTIARA ELASTICINDO
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PT. No. a17
CA Area Cil€gon Date 16-Feb-21

: l,Yildan Jalaludin - Site Co - PGN PGAS'S PIC : Ardhiansyah - Site Manager

: Benhu. Wahyudin - Prcioct Manager - pGN Sotution HP : 0813 6652 2?45

NO ACTIVIIIES TIME LOCATION'KP TYPE OF REPORT TYPE OF TNSPECT REIi/!ARKS Plc

Joshua
1 Test Pit 0e.00 - 17.00 Jl Kaserangan - Pengampelan BA Report Continue
(0812 9161 0654)

Santana
2 PQT 08.00-17.00 Jl Kaserangan - Pengampelan BA Report Continue
{4a12 2AM 17AO)

Date of lnspection 17-Feb-21

08.00 " 17.00
E] Joint Suryey

tf Material V€rifl cation/Preparation

fI Wiinessing of Testing

tl Release Hold Point

m Onry this Report I-Tl orawins

u lnspection Reporl
[} Suruey Reporl
t:] Visual for NDT

n Testing Repon
f] Heavy Equipment Report
t:] Punch List

t_l Final Inspeciion

t:] Equipment and Tools lnspeclion

RESULT/CONCLUSION (by Employer/Engineer):

Lll Test / lnspection Result Satisfactory

E No Objection & Proceed for Next Wolk

B Test I lnspection Result Unsatisfactory E No Ofiiection with Remarks

C Requires Re-Work and or Re-Test F

If result is B. C or E, please put the note below:

Prepar€d by Reviewed by
PT. PGAS Solution

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Date 17.Feb.21 Date I
 $0tufloN PROYEK CUSTOMER ATTACHMET'IT
AREA CILEGON . CV MUTIARA ELASTICINDO
o
Request No. 018
CA Area Cilegon Date 17-Feb-21

: Wildan Jalaludin - Site Co - PGN PGAS'S PIC Ardhiansyah - Site Managar

r Benhur Wahyudin - Prciect llanager - PGN Solution HP oa13 6652 2245

NO ACTIVITIES TIME LOCATION/KP TYPE OF REPORT TYPE OF INSPECT REi,IARKS Prc

Joshua
1 Test Pit 08.00 - 17.00 Jl Kaserangan - Pengampelan BA Report Cont:nue
(0812 9161 0654)

Joshua
2 NDT 08.00-1 7.00 Workshop Karawano Repo( Continue
(0812 9161 0654)

Dats of lnspection 1A-Fab-21

08.00.17.00
fl Joint Survey

ul Material Verifi cation/Preparation

tI Witnessing of Testing

n Reiease Hold Point

m Oniy this Repol1

fl Drawine

u lnspection Reporl
f] suruey Report
tl Visual for NDT

TT Testing Repo(
tr HeaW Equipment Report
E Punch List

t_l Final lnsprction

t:] Equipment and Tools ,nspection

RESU LTICONCLUSION (by EmployerlEnglneer):

Test i lnspection Result Satisfactory D No Objection & Proceed for Next Woft

tr Test / lnspeclion Result Unsatisfactory No Objectian with Remarks

c Requires Re-Work and or Re--fesl F

It result is B, C or E, pJease put the note below:

Prepared by Reviewed by
PT. PGAS So,ution PT. Perusahaan Gas Negara Tbk.

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Date 18-Feb-2{ Oate .Lr
 $OLUTION PROYEK CUSTOMER ATTAGHMENT
AREA CILEGON . CV MUTIA.RI\ ELASTICINDO

To PT. Perusahaan Gas Negara Tbk, Request No. 019

CA Area Cilegon Date 18.Feb-21

Attn : Wlldan Jalaludin - Site Co , PGN PGAS'S PIC ; Ardhiansyah ' Site Manager

Cc : Benhur Wahyudin - Proiect Manager - PGN Solution HP : 0813 6S52 22.15

DETAIL OF ACTIVITIES

NO I\CTIVITIES TIME LOCATION'KP TYPE OF REPORT TYFE OF INSPECT REMARKS Prc

Joshua
1 Test Pit 08.00, 17.00 Jl Kaserangan - Pengampelan BA Report Continue
(0812 9'161 0654)

19-Feb-21 Joinl Sufrey

08.00. r7.oo
n [,laterial Verilication/Preparation

tl
3n,
Witnessing oi Tesiing

t:] Release Hold Point

E Oniy this Report

-_
L1l urawrng

[] Visual fo. NDT

n lnspetion Repod I Suruev Report

t_l Punch List

tr Testing Report I Heavy Equipment Repori

I Finai lnspection

f Equipment and Toois lnspection

RESULTICONCLUSION (by Employ€/Engineer):

E Test / lnspection Result Satjsfactory

E No Objection & Prcceed for Next Work

tr Test / lnspection Result Unsatisfactory E No Obiection with Remarks

tr Requires Re-Work and or Re-Test

E
lf result is B, C or E, please pul lhe note bslow:

Preper€d by Reviewed by
PT. PGAS Solution PT. Perusahaan Gas Negara Tbk.

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Date 19+eb-21 Date 4 ,{
 -
$0llrnoN PROYEK CUSTOMER AfiACHMENT
AREA CILEGON, CV MUTIARA ELASTICINDO
o
To Perusahaan Gas Negara Tbk. Request No. 020
CA Area Cilegon Date 1g-Feb-21

: Wildan Jalaludin - Site Co - PGN PGAS'S PIC : Ardhiansyah - Site Manager

: Berhur Wahyudin - Project Manager - PGN Solution HP o813 6652 2245

NO ACTIVITIES TIME LOCATION'KP TYPE OF REPORT TYPE OF INSPECT REMARKS Ptc

Joshua
1 Test Pit 0B 00 - 17"00 Jl Kaserangan - Pengampelan BA Report Continue
(0812 9161 0654)

Workshop Kebon Jeruk- Mess Joshua

Mobilisasi HDD 08.00 - Selesai BA Repod Continue
SeraBg (0812 9161 0654)

Dato of lnapetion 20-Feb-2'l

08.00 - 17.00
t:] Joint Survey

Place Kebon Jeruk- l\ress

I Material Verif i€tion/p€paration

fl Witnessing of Tesiing

tl Reiease Hold Poini

m
t:
Onlv llris Reporl [Tl Drawins
Visual for NDT

n lnspection Report
f| suruey Report
E Punch List

tr Tesling Report
I Heavy Equipment Report

t:] Final Insp*tion

t_l Equipment ancj loojs lnspection

RESU LT/CONCLUSION (by EmployerlEngineer):

E Test r' ]nspection Result Salisfactory D No Objection & Poceed for Next Work

t-;1 Tesl I inspection Result Unsatisfactory

t"l E No Cbjection with Rema!*s

E Requires Re-Work and or Re-Test F

lf result is B, C or E, please put the note below:

Prepared by Reviewed by
PT. PGAS Solution PT. Perusahaan Gas Negara Tbk.

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Date 20-Feb-21 Date >1 D-r
 SOLUTION PROYEK CUSTOMER ATTACHMENT
AREA CILEGOH . GV MUTIARA ELASTICIHDO
e
Requst No. o21
CA Area Cilegon Date zA-Feb-21

: Wildan Jalaludin ' Site Co - PGN PGAS'S PIC : Ardhiansyah - Site Manager

: Benhu{ Wahyudin - Prciect Manager - PGN Solution HP oa13 6652 2245

NO ACTIVITIES TIME LOCATION'KP TYPE OF REPORT TYPE OF INSPECT REMARKS Plc

Joshua
1 Test Pit 08.00 - 17.00 Jl Kaserangan - Pengampelan BA Report Continue
(0812 S161 0654)

Joshua
Setting Mesin HDD 08.00 - 17.00 il Kaserangan - Pengampeian BA Report Continue
(0812 9161 0654)

of lnsp€ction 21-Feb-21
08.00 " 17.00
tf Joinl Sufrey

E Material Verifi cation/Preparation

fl Witrsssing of Testinq

fl Release Hold Poini

m Only this Report l-Tl or"*tns

n lnspection Report
f| suruey Repon
tl Visual for NOT

tr Testing Repod
l-
Lll Heavy tqurpmenl RePort
tl Punch List

tf Final lnspedion

f] Equipment and Tools Inspection

RESULTICONCLUSION (by Employer/Engineer):

Test / lnspectior Result Satisfactory D No Objection & Proceed for Next Work

B lest / lnspeclicn Result Unsiislactory IE-i ruo Ooiectton with Remarks

c Requires Re-Work and or Re-Test F

lf result is B, C or E, piease put the note below:

Prepared by Reviswed h,y

PT^ PGAS Solution PT. Perusahaan Gas Negara Tbk,

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oate 2t-Feb.21 Oate 4t
 -
SOTUIION PROYEK CUSTOMER ATTACHMENT
AREA GILEGON - CV MUTIARA ELASTIGINDO
a
CA Area Cilegon Date 21-Feb-21

Wlldan Jalaludin. Site Co . PGN PGAS'S PIC : Ardhiansyah . Sita Manager

: Bcnhur $Jahyudin - Prciect Manager - PGN Sotution HP : 0a13 6652 2245

NO ACTIVIIIES TIME LOCATION'KP TYPE OF REPORT TYPE OF INSPECT REMARKS Ptc

Joshua
1 Test Pit 08.00 - 17.00 Jl Kaserangan' Pengampelan BA Reporl Continue
(0812 9161 0654)

Joshua
2 Trenching 08.00 - 17.00 Jl Kaserangan - Pengampelan BA Report Continue
i0812 9161 065.1)

Joshua
3 lnstall Shoring 08.00 - 17 00 Jl Kaserangan - Pengampelan BA Repod Continue
(0812 9161 0654)

Joshua
4 Boring HDD Span I 08.00 , 17.00 Jl Kaserangan - Pengampelan BA Repod Continue
i0812 9161 0654)

Josirua
5 Slringing 08 00, 17.00 Jl Kaserangan - Pengampelan BA Report Continue
(0812 9161 0654)
Joshua
6 WelCing Pipe 08 00 - 17.00 Jl Kaserangan * Pengampelen BA Report Continue
(0812 9161 0654)

o.f lnsFeclion 22-Feb-21

08.00 " 17.00
if Joint Survey

fl Material Vedfiction/Preparation

il Witnessing of Testing

n Release Hold Poinl

tr Only this Repori El Drawins

E fl
t:] Visual for NDT

E
lnspection Repon Suruev neoort
Funch List

u -festing
Report Lf-l Heavy Lqurpment Heport

fl Final lnspection

t_l Equipment and Toois Jnspection

RESULTICONCLUSION (by Emptoyer/Engineer)i

Test / lnspection Result Satisfactory

T;I No ObJection & Prcceed for Next Work
L:I

tr Tesl J lnspection Result Unsalisfaelory l.lo Objection with Remarks

Requires Re-Work and or Re-Test F

If result is B. C or E, ptease put the note below:

PrepEred tly Reviewed by

PT. PGAS Solution PT. Perusahaan Gas Negara Tbk.

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Date 22"Feb-21 Date 5r