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. Nama umum/dagang/kode HS: .B ...U..A ...H...D...U ...R..I.A...N..;............................................................................................................

2. Nama ilmiah**): .D ...u
..r..i.o...z..i.b..e..t.h
..i.n
..u...s..;................................................................................................................................
3. Bentuk dan jumlah): .B ...u..a..h...4..5..0...K...I.L..O...G ...R..A...M...;.................................................................................................................
4. Bahan pembungkus/kemasan: .C ..O...L ..I../..J
..U...M...L..A ...H...K...E ..M...A...S
..A...N...:..1..8....K ..O
...L..I.........................................................................
5. Tanda/merek pada pembungkus/kemasan: .S ..E
...G ...E..L...K...A..R
...A...N..T..I.N...A..................................................................................
6. Jumlah dan nomor peti kemas**): .= ..=..=...=..=..=..=..=..=..=
..= ..=..........................................................................................................
7. Nama dan alamat pengirim: .I.S ...M...A ..I.L
................................................................................................................................
.B
...E..N
...G
...K
..U...L
..U
.....................................................................................................................................................................
........................................................................................................................................................................................
8. Nama dan alamat penerima: .Y ..A...N...T..O ..............................................................................
.J
...A..K
...A
..R
...T..A
........................................................................................................................................................................
........................................................................................................................................................................................
9. Tujuan pengeluaran: .1 ..-..K..O...N...S..U...M ...S..I...............................................................................................................................
10. Area asal dan tempat pengeluaran: K ...O...T..A....B..E ...N..G...K...U..L..U.../.B
...a..n..d..a..r..U
...d..a..r..a...F..a..t.m
...a..w
...a..t.i..S
...o..e..k..a..r.n
..o
....................................
11. Area tujuan dan tempat pemasukan: K ...O...T..A ...J ..A
...K...A ..R...T..A
....P..U...S..A...T../.B..a
..n...d..a..r..U...d..a..r.a
...S
...o..e..k..a..r.n
...o...H ..a
..t..t.a..,..C
..e
..n
...g..k..a..r.e..n
..g
..........
12. Jenis dan nama alat angkut: .P ...E..S...A ..W....A ..T...U...D ...A..R...A../.-.......................................................................................................
13. Tanggal berangkat: .1 ..5
...A ...g..u..s..t..u..s...2..0..1..9...........................................................................................................................

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: B
...E
..N
...G...K..U...L..U
.....................
Pada tanggal: 1..5...A
...g..u..s..t.u
..s
...2
..0
..1
..9
.............
Petugas Karantina Tumbuhan

H
...A
...S..A
...N..U...D..I.N..........................................
NIP..1 ...9..7..9..0..1..0..1..2..0..0..5..0..1..1..0..0..1..................
*) Diisi bila perlu dan/atau memungkinkan.

Printed 31/08/2019 05.24.02