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PEMERINTAH KOTA KEDIRI

DINAS KESEHATAN KOTA KEDIRI


PUSKESMAS KOTA WILAYAH UTARA
Jl. Ratulangi No.12 Telp. (0354) 683227

LAPORAN GANGGUAN / KERUSAKAN SARANA PRASARANA DAN PERALATAN

POLI / UNIT : ...............................................................................................

JENIS KERUSAKAN / GANGGUAN : ...............................................................................................

...............................................................................................

...............................................................................................

Kediri, ..........................................
Penerima Laporan Pelapor

(...........................................) (...........................................)

PEMERINTAH KOTA KEDIRI


DINAS KESEHATAN KOTA KEDIRI
PUSKESMAS KOTA WILAYAH UTARA
Jl. Ratulangi No.12 Telp. (0354) 683227

LAPORAN GANGGUAN / KERUSAKAN SARANA PRASARANA DAN PERALATAN

POLI / UNIT : ...............................................................................................

JENIS KERUSAKAN / GANGGUAN : ...............................................................................................

...............................................................................................

...............................................................................................

Kediri, ..........................................
Penerima Laporan Pelapor

(...........................................) (...........................................)

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