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PERMIT APPLICATION

Survey Form
INSTITUTION : DINAS PEKERJAAN UMUM, PERTAMBANGAN & ENERGI PERMIT : IJIN OPERASI PEMBANGKIT LISTRIK

No

Des r!"#!o$

RE%IE&

M.S ANGWARMASE.ST.MSI KABID PERTAMBANGAN & ENERGI 1 Name Of Section/Directorate Y !I S MANGENDE KASIE PERTAMBANGAN & ENERGI

M.S ANGWARMASE.ST.MSI &NO 'P( )*1+,+11**-,. " #ontact $er%on Y !I S MANGENDE &NO 'P( )*1+,""/,0*+.

Permit/!icen%e De%cri$tion

I1IN OPERASI PEMBANGKIT !ISTRIK

P2r$o%e

NT K KEPER! AN PENERANGAN ATA OPRASIONA! KANTOR3 D!!

Reference%( !a4/Decree/Re526ation

BE! M ADA PERDA ATA KEP T SAN B PATI YANG MENGAT R TENTANG I1IN OPERASI PEMBANGKIT !ISTRIK

Ot7er A2t7orit8/In%tit2tion In9o69e: &if an8.

BAPEDA MENGA# KE PERAT RAN MENTERI ESDM

Tec7nica6 Permit #6a%%ification( Non; Tec7nica6 1. S RAT PERMO'ONAN KEPADA B PATI ".#<. KEPA!A DINAS P 3 PERTAMBANGAN DAN ENERGI +.PETA/ GAMBAR !OKASI ,. AKTE PENDIRIAN PER SA'AAN 0. S RAT KETERANGAN DOMISI!I PER SA'AAN / Doc2ment% Re<2ire:( -. S S NAN PENG R S DAN #OPY KTP /.TANDA DA=TAR PER SA'AAN &TDP. *.NPWP PER SA'AAN >. DATA KAPASITAS PEMBANGKIT 1).SI P

St2:8 re$ort S2r9e8 re$ort Ot7er Doc2ment%( In%$ection re$ort De%i5n Re$ort Ot7er &%$ecif8.

Detai6 Proce:2re( &Narrati9e an: =6o4 #7art.

1. ". +. ,.

S RAT PERMO'ONAN DIE?A! ASI DAN DIKA1I O!E' TIM TEKNIS PENGE#EKAN !OKASI PEMBANGKIT DIKE! ARKAN REKOMENDASI DARI KEPA!A BADAN/ DINAS DIA1 KAN KE B PATI NT K MEMPERTIMBANGKAN / MENERBITKAN S RAT KEP T SAN PERI1INAN ATA KEGIATAN TERKAIT

>

Detai6 D2ration to a$$68(

";- 'ARI KER1A KEPA!A DINAS MENGE! ARKAN REKOMENDASI TENTANG PERI1INAN TERKAIT KEPADA B PATI ";- 'ARI KER1A B PATI MENGE! ARKAN S RAT KEP T SAN &#ATATAN . B PATI ADA DITEMPAT.

1) 11

Permit% / !icen%e ?a6i:it8( A%%ociate: co%t( &O$erationa6 #o%t. BE! M ADA PERDA MASI' PROSES PENY S NAN

TAMBA'AN S RAT KEP T SAN DARI B PATI ( &TER!AMPIR. 1. 1" Note( ". PERAT RAN B PATI MA! K TENGGARA BARAT NOMOR. +* TA' N ")1+ TENTANG PEMBINAAN3 PENGAWASAN DAN PENYA! RAN BA'AN BAKAR MINYAK KEP T SAN B PATI MA! K TENGGARA BARAT NOMOR -));-1> TA' N ")1" TENTANG PENETAPAN 'ARGA DASAR 1ENIS;1ENIS MATERIA! MINERA! B KAN !OGAM DAN BAT AN

A$ E'(m")e *or A"")! (#!o$ Pro e+ure ($+ Perm!# Issu!$, -P)e(se mo+!*y (s $ee+e+.
Part8 Acti9it8 1. Submitting Application #om$an8 #o2nter

A$$68

?erification
Dur(#!o$

2. Application Evaluation

No

Pa%% @

Ye%

Dur(#!o$

Dur(#!o$

Di%$o%ition

Di%$o%ition

@@@@

Dur(#!o$

3. Approval
Get Permit

Ye%

Pa%% @
No

Ye% No

Ye%

Pa%% @
No

Pa%% @

Pro e+ures 1. Company submit the application includes: a. Request letter b. Administration requirements: i. A ii. iii. C iv. !

v. E vi. " vii. # viii. $ i%. & %. ' %i. c. (echnical requirements: i. ) ii. * iii. + iv. , v. vi. . vii. / viii. d. -ther requirement as i0 needed 2. (he application then 1ill be veri0ied by counter o00icer 3. .assed to 22222222222222222222222222222222222 3. .assed to 22222222222222222222222222222222222 4. R

5. S 6. ( 7. 8 9. : 1;. < Note. a. All activities ta=e about 2222222 1or=ing days b. &0 some requirements 0ail in evaluation> company request to apply again ?0rom step 1@.

!i%t of Permit(
No
1 " + , 0 / * > 1) 11 1" 1+

PERMIT/LICENSE DESCRIPTION
Pro7iAite: Area% an: #onfine: Area Permit% for enterin5 Oi6 an: 5a% Area Pre%%2re ?e%%e6 #ertification Pe:e%ta6 #rane #ertification Rotatin5 E<2i$ment E6ectrica6 E<2i$ment #ertification =6o46ine &inc62:in5 =6eBiA6e $i$e6ine. !NG TanC !NG In%ta66ation/P6ant Pre%%2re Safet8 ?a69e% =ina6 Po$$in5 Te%t We6:er% Performance We6:in5 Proce:2re% E2a6ification A$$ointin5 'ea: of Safet8 of Mine &Ke$a6aIn%$eC%i. A$$ointin5 Officer for %ea6 & 2n%ea6e: Pre%%2re Safet8 ?a69e re$re%entin5 Directorate Tec7ni<2e of MIGAS #entra6iDe: Stora5e 2%e of 'aDar:o2% Wa%te &B+. De%a6ination Di%c7ar5e Permit '8:rote%t Water Di%c7ar5e Permit Water Di%c7ar5e Permit D2rin5 O$eration Permanent 'aDar:o2% Stora5e for O$eration Emi%%ion from Non Point &Stationar8. So2rce Permit Noi%e !e9e6 Permit O:or !e9e6 Permit ?iAration !e9e6 Permit Incinerator% Permit% &O$eration Permit. =ore%tr8 Re6ea%e Permit 'e6i:ecC #on%tr2ction Permit 'e6i$a: #on%tr2ction Permit O$erationa6/6an:in5 Permit for 'e6ico$ter 'e6i:ecC O$eration Permit =PSO In:one%ia =6a5 =PSO #on%tr2ction B2o8% for 52i:ance #ar5o S7i$% to =PSO Sti$26ation on S$ecia6 Termina6 6ocation #on%tr2ction Permit for S$ecia6 Termina6

PURPOSE
Pro7iAite: to enter area of =PSO Permit for ?e%%e6 enterin5 area of Oi6 an: Ga% E<2i$ment Safet8 Wort7ine%% #ertificate E<2i$ment Safet8 Wort7ine%% #ertificate E<2i$ment Safet8 Wort7ine%% #ertificate E<2i$ment Safet8 Wort7ine%% #ertificate E<2i$ment Safet8 Wort7ine%% #ertificate E<2i$ment Safet8 Wort7ine%% #ertificate In%ta66ation O$erationa6 Safet8 Wort7ine%% Permit to en%2re Pre%%2riDe E<2i$ment are Protecte: $er De%i5n !icen%e for 4e6:er $erformance A$$ro9a6 for We6:in5 Proce:2re% Actin5 a% Directorate Tec7ni<2e MIGAS for ca%e of emer5enc8 an: a66 o$erationa6 tec7nica6 %afet8 a%$ect% of P6ant. Actin5 a% Directorate Tec7ni<2e MIGAS to %ea6 an: 2n%ea6e: of A66 Pre%%2re Safet8 ?a69e% in ca%e of 2r5enc8 of t7e P6ant. Permit% for meetin5 re526ation% re<2irement% Permit% for meetin5 re526ation% re<2irement% Permit% for meetin5 re526ation% re<2irement% Permit% for meetin5 re526ation% re<2irement% Permit% for meetin5 re526ation% re<2irement% ; D2m$in5 Permit ; !an:fi66 Permit Permit% for meetin5 re526ation% re<2irement% Permit% for meetin5 re526ation% re<2irement% Permit% for meetin5 re526ation% re<2irement% Permit% for meetin5 re526ation% re<2irement% Permit% for meetin5 re526ation% re<2irement% Permit% for meetin5 re526ation% re<2irement% Permit for #on%tr2ction of 'e6i:ecC Permit for #on%tr2ction of 'e6i$a: Permit for O$erationa6 of 'e6ico$ter Permit for o$eration of 'e6i:ecC %in5 In:one%ia =6a5 A$$ro9a6 for #on%tr2ction of =PSO Permit for $6acin5 B2o8% at a$$ointe: $oint% !ocation $ermit re%$ecti9e68 for on%7ore Fett8 &if an8. an: t7e =!NG a% S$ecia6 Termina6 #on%tr2ction $ermit re%$ecti9e68 for on%7ore Fett8 &if an8. an: t7e =!NG a% S$ecia6 Termina6

1,

10 11/ 1* 1> ") "1 "" "+ ", "0 ""/ "* "> +) +1 +" ++ +,

No
+0 ++/ +*

PERMIT/LICENSE DESCRIPTION
O$eration Permit for S$ecia6 Termina6 WorCin5 Permit for n:er Water 4orC Di%$en%ation for 2%in5 =orei5n =6a5 ?e%%e6 for Dri66in5 Acti9itie% &IzinPenggunaanKapalAsing. Di%$en%ation for 2%in5 =orei5n =6a5 ?e%%e6 for In%ta66ation/#ommi%%ionin5 Acti9itie% &IzinPenggunaanKapalAsing. Permit for Marine Te6ecomm2nication O$eration Permit Gro2n: A9iation Ra:io Station Dre:5in5 4orC% $ermit O$eration Wort7ine%% Permit for ?e%%e6 &Surat IzinLayakOperasi. S$ecia6 ?e%%e6 O$eration Permit/SIOPS S !NG TanC ?o62me #a6iAration #ertificate% #2%to:8 Tran%fer Mea%2rement S8%tem Permit ; #a6iAration %a5e

PURPOSE
O$eration $ermit re%$ecti9e68 for on%7ore Fett8 &if an8. an: t7e =!NG a% S$ecia6 Termina6 A66 2n:er4ater 4orC %7a66 7a9e $ermit from Go9ernment Di%$en%ation for 2%in5 #ate5or8 # an: B ?e%%e6 Di%$en%ation for 2%in5 #ate5or8 # an: B ?e%%e6

+> ,) ,1 ," ,+ ,, ,0 ,,/ ,* ,> 0) 01 0" 0+ 0, 00 0/ 0* 0>

Marine #omm2nication Permit% for O$eration of #re4 Aoar:3 9e%%e63 etc Permit% for Gro2n: Ra:io for =6i57t S$ecia6 Termina6 #on%tr2ction Permit for ?e%%e6 for O$eration in Oi6 an: 5a% Area Permit for =!NG a% a 9e%%e6 to o$erate 4it7in In:one%ian 4ater3 a% faci6it8 %2$$ortin5 t7e oi6 an: 5a% o$eration Permit% for meetin5 re526ation% re<2irement% in fi%ca6/Mea%2rement nit S8%tem Permit% for meetin5 re526ation% re<2irement% in fi%ca6/Mea%2rement nit S8%tem Permit% for meetin5 re526ation% re<2irement% in fi%ca6/Mea%2rement nit S8%tem =or im$ortation of materia6%/Goo:% Permit for Im$ort of Goo:% an: Materia6% &EBce$tion of Im$ort D2t8. Permit for Im$ort of Goo:% an: Materia6% &EBce$tion of Im$ort D2t8. In re%$ect of forei5n 6oan if t7e ProFect i% $roFect finance: Permit a% Ba%i% for De$artment of 12%tice to i%%2e KITAS for =orei5n WorCer Permit a% Ba%i% for De$artment of !a4 an: '2man Ri57t% to i%%2e KITAS for =orei5n WorCer Permit for 2%in5 6iftin5 E<2i$ment. Permit% for %a5e of Marine Ra:io Permit% for S$ecia6 Te6ecomm2nication Permit for Wa6Cie Ta6Cie Permit To com$68 4it7 Go9ernment Re526ation Ma$$in5 of t7e ProFect !ocation into In:one%ia #7art Permit to 2%e !.O $er%onne6 :2rin5 con%tr2ction3 in%ta66ation 4orC Permit for 2%in5 S2r9e8 ?e%%e6 an: %2r9e8 acti9itie% Permit for #6inic %a5e Permit for P7armace2tica6/Me:icine% Permit for $arame:ic% acti9itie%

#2%to:8 Tran%fer Mea%2rement S8%tem %a5e Permit;#a6iAration for Internationa6 Tra:e Pro:2cer Im$orte: !icen%e &API;P. Ma%ter !i%t #a$ita6 Goo:% Im$ort Goo:% P6an &RIB. A$$ro9a6 of =orei5n #ommercia6 !oan &PK!N. WorCin5 Permit for =orei5n Per%onne6; INPEG Em$6o8ee &RPTKA & IMTA. WorCin5 Permit for =orei5n Per%onne6 for #ontractorH% &RPTKA & IMTA. #ertification of !iftin5 E<2i$ment in On%7ore. &Non Oi6 an: Ga% P6ant. Ra:io #omm2nication Permit &Izin Pita SpektrumFrekuensi Radio. Princi$6e Permit of S$ecia6 Te6ecomm2nication Arran5ement Permit Ra:io an: #omm2nication =re<2enc8 Permit =or %in5 D2rin5 #on%tr2ction/#ommi%%ionin5 Permit to 2%e3 Store an: Tran%$ort of Ra:ioacti9e materia6% S2r9e8 & Ma$$in5 !icen%e Officer &!O.

-" -+ -, -0

S2r9e8 ?e%%e6 Permit #6inic =aci6it8 !icen%e P7armace2tica6 Stora5e !icen%e Occ2$ationa6 7ea6t7 an: %afet8 &com$an8 :octor%3 $arame:ic officia6%3 an: eB$atriate $78%ician.

No
--/ -* -> /) /1 /" /+ /, /0 /// /* /> *) *1 *" *+ *, *0 **/

PERMIT/LICENSE DESCRIPTION
Sec2rit8 #6earance EB$6o%i9e Materia6% Pro:2ction3 Proc2rement3 Stora5e3 an: Di%triA2tion Permit B2i6:in5 Permit for Ba%e #am$ &IMB. !an: Ac<2i%ition &IzinLokasi. !an: O4ner%7i$ &'aCG2naBan52nan. Permit to %e Po4er Generator &IzinOperasi. !etter of Recommen:ation from Re5iona6 Go9ernment &B PATI. for S$ecia6 Termina6 Permit to %e 'ea98 E<2i$ment from P2A6ic WorC% Office;Re5iona6 Go9ernment &KAB PATEN. #om$26%or8 Re$ort of #om$an8H% eBi%tence em$6o8ee in t7e re5ion Permit for :oin5 A2%ine%% in t7e re5ion #om$26%or8 Re$ort of #om$an8H% eBi%tence em$6o8ee in t7e re5ion B2i6:in5 Permit &IMB. B2i6:in5 Permit &IMB. B2i6:in5 Permit &IMB. Permit% of Gro2n: Water EBtraction Permit% of S2rface Water %a5e B2i6:in5 Permit &IMB. #on%tr2ction Permit Site Re$re%entati9e Office !etter of Domici6e of INPEG/#ontractor !an:in5 Permit for 'ea98 D2t8 #on%tr2ction E<2i$ment =2e6 A66ocation for ProFect P2r$o%e/Ann2a6 A66ocation EB$6o%i9e materia6 $ermit

PURPOSE
Permit for Enterin5 In:one%ia Water

Permit for B2i6:in5 Aot7 Tem$orar8 an: Permanent Permit for B2i6:in5 Aot7 Tem$orar8 an: Permanent =aci6itie% !an: Ri57t %e: =or ti6iDation of Po4er if INPEG Wi66 $ro9i:e O4n Po4er Generator Recommen:ation !etter for S$ecia6 Termina6 Permit for 2%in5 'ea98 E<2i$ment Re$ortin5 on c2rrent n2mAer of Nationa6 an: forei5n em$6o8ee 4orCin5 in t7e re5ion To re5i%ter INPEG office in t7e re5ion Re$ortin5 on c2rrent n2mAer of Nationa6 an: WorCin5 Permit of forei5n em$6o8ee t7at are 4orCin5 in t7e re5ion EB$6o%i9e & Detonator Stora5e #on%tr2ction of =2e6 Stora5e #on%tr2ction of 'an5ar & ot7er A2i6:in5% &Permanent & Tem$orar8. %a5e of Gro2n: Water S2rface Water #6inic =aci6it83 Dinin5 & Kitc7en =aci6it8 Infra%tr2ct2re #on%tr2ction &P2A6ic Roa: & Draina5e. =or Re$ office Aefore =EED P7a%e &Tem$orar8 . Permit for :omici6e Permit for 2%a5e of 'ea98 E<2i$ment !etter of a$$ro9a6 for %2$$68in5 f2e6 for INPEG On S7ore o$eration