DEPARTEMEN KESEHATAN R.I.

BALAI BESAR LABORATORIUM KESEHATAN SURABAYA

Jln. Karangmenjangan 18
S u r a b a y a ( 60286 )

LAPORAN MUTASI ALAT / BARANG

Diberitahukan bahwa Alat Lab. / Barang dengan data :

Nama Alat Lab. / Barang : .......................................................................................................

Merk / Type / No. Seri : .......................................................................................................

Volt / Frek / Tahun : .......................................................................................................

No. Inventaris : .......................................................................................................

Kondisi Alat / Barang : .......................................................................................................

Di Mutasi Ke : .......................................................................................................

Asal Alat / Barang : .......................................................................................................

Tanggal Mutasi : .......................................................................................................

Demikian atas kerjasamanya, diucapkan banyak terima kasih.

Surabaya, ..............................
Penanggung Jawab .
Ruangan Penerima Alat / Barang
Mutasi

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NIP. ............................. ___________________
NIP. .............................

Mengetahui
Kepala Instalasi

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NIP. .............................

Form 16-MT