*4D3468CE5B66CA65* No.

:
REPUBLIK INDONESIA
KEMENTERIAN PERTANIAN
BADAN KARANTINA PERTANIAN
KT - 12

SERTIFIKAT KESEHATAN TUMBUHAN ANTAR AREA

No: 2019.2.2702.0.K12.K.001284

Berdasarkan Undang-Undang Nomor 16 Tahun 1992 tentang Karantina Hewan, Ikan, dan Tumbuhan dan peraturan
pelaksanaannya dan hasil tindakan karantina tumbuhan, menyatakan bahwa media pembawa di bawah ini:

1. BUAH DURIAN;
Nama umum/dagang/kode HS: ......................................................................................................................................
2. Durio zibethinus;
Nama ilmiah**): ..............................................................................................................................................................
3. Buah 450 KILOGRAM;
Bentuk dan jumlah): .......................................................................................................................................................
4. COLI / JUMLAH KEMASAN: 18 KOLI
Bahan pembungkus/kemasan: .......................................................................................................................................
5. SEGEL KARANTINA
Tanda/merek pada pembungkus/kemasan: ...................................................................................................................
6. ============
Jumlah dan nomor peti kemas**): ..................................................................................................................................
7. ISMAIL
Nama dan alamat pengirim: ...........................................................................................................................................
BENGKULU
........................................................................................................................................................................................
........................................................................................................................................................................................
YANTO
8. Nama dan alamat penerima: .........................................................................................
JAKARTA
........................................................................................................................................................................................
........................................................................................................................................................................................
1-KONSUMSI
9. Tujuan pengeluaran: ......................................................................................................................................................
10. Area asal dan tempat pengeluaran: KOTA BENGKULU/Bandar Udara Fatmawati Soekarno
..............................................................................................................................
11. Area tujuan dan tempat pemasukan: KOTA JAKARTA PUSAT/Bandar Udara Soekarno Hatta, Cengkareng
............................................................................................................................
PESAWAT UDARA/-
12. Jenis dan nama alat angkut: .........................................................................................................................................
15 Agustus 2019
13. Tanggal berangkat: .......................................................................................................................................................

telah memenuhi semua persyaratan yang ditetapkan bagi pengirimannya ke area tujuan serta bebas dari
organisme pengganggu tumbuhan karantina dan organisme pengganggu tumbuhan penting.

KETERANGAN TAMBAHAN**)
=================
..............................................................................................................................................................................................
..............................................................................................................................................................................................
..............................................................................................................................................................................................

PERLAKUAN**)

1. =================
Tanggal: ...........................................................................................................................................................................
2. =================
Jenis perlakuan: ...............................................................................................................................................................
3. =================
Jenis pestisida/bahan yang digunakan: ...........................................................................................................................
4. =================
Konsentrasi/dosis: ............................................................................................................................................................
5. =================
Durasi dan temperatur: .....................................................................................................................................................
6. =================
Informasi tambahan: .........................................................................................................................................................

Diterbitkan di: BENGKULU

.......................................
Pada tanggal: 15 Agustus 2019
.......................................
Petugas Karantina Tumbuhan

HASANUDIN
.............................................................
197901012005011001
NIP.......................................................

*) Diisi bila perlu dan/atau memungkinkan.

Printed 31/08/2019 05.24.02