No. Dok.

:
PT PLN (PERSERO)
UNIT INDUK PEMBANGKITAN TANJUNG JATI B
Berlaku sejak : 01 Januari 2019

Revisi : 02
Formulir Notifikasi Pekerjaan
Tanggal Pengajuan :

NOTIFICATION OF OVERTIME/HOLIDAY WORK

Pemohon, : Disetujui Oleh, :

Nama : ______________________ Nama : ______________________

Jabatan : ______________________ Jabatan : ______________________

1. Hari, Tanggal & Waktu :

2. Lokasi Pekerjaan :
3. Aktivitas Pekerjaan :

4. Jenis Material :

5. Penanggungjawab :
6. No. Telefon :
7. Data Pekerja :
(Nama & Jabatan)

Disetujui Oleh,
EHS O&M PT. PLN (Persero) Pembangkitan Tanjung Jati B

K3L

* Overtime : di atas jam 17.00 wib dan di hari libur

* Lampiran berupa foto kopi KTP/SIM yang asih berlaku

 No. Dok. : 3.2.6.F1
PT PLN (PERSERO)
UNIT INDUK PEMBANGKITAN TANJUNG JATI B
Berlaku sejak : 01 Januari 2019

Revisi : 02
Formulir Notifikasi Pekerjaan
Tanggal Pengajuan :

NOTIFICATION OF OVERTIME/HOLIDAY WORK

Pemohon, : Disetujui Oleh, :

Nama : ______________________ Nama : ______________________

Jabatan : ______________________ Jabatan : ______________________

1. Hari, Tanggal & Waktu :

2. Lokasi Pekerjaan :
3. Aktivitas Pekerjaan :

4. Jenis Material :

5. Penanggungjawab :
6. No. Telefon :
7. Data Pekerja :
(Nama & Jabatan)

Disetujui Oleh,
EHS O&M PT. PLN (Persero) Pembangkitan Tanjung Jati B

K3L

* Overtime : di atas jam 17.00 wib dan di hari libur

* Lampiran berupa foto kopi KTP/SIM yang asih berlaku
 No. Dok. : 3.2.6.F1
PT PLN (PERSERO)
UNIT INDUK PEMBANGKITAN TANJUNG JATI B
Berlaku sejak : 01 Januari 2019

Revisi : 02
Formulir Notifikasi Pekerjaan
Tanggal Pengajuan :

NOTIFICATION OF OVERTIME/HOLIDAY WORK

Pemohon, : Disetujui Oleh, :

Nama : ______________________ Nama : ______________________

Jabatan : ______________________ Jabatan : ______________________

1. Hari, Tanggal & Waktu :

2. Lokasi Pekerjaan :
3. Aktivitas Pekerjaan :

4. Jenis Material :

5. Penanggungjawab :
6. No. Telefon :
7. Data Pekerja :
(Nama & Jabatan)

Disetujui Oleh,
EHS O&M PT. PLN (Persero) Pembangkitan Tanjung Jati B

K3L

* Overtime : di atas jam 17.00 wib dan di hari libur

* Lampiran berupa foto kopi KTP/SIM yang asih berlaku
 No. Dok. : 3.2.6.F1
PT PLN (PERSERO)
UNIT INDUK PEMBANGKITAN TANJUNG JATI B
Berlaku sejak : 01 Januari 2019

Revisi : 02
Formulir Notifikasi Pekerjaan
Tanggal Pengajuan :

NOTIFICATION OF OVERTIME/HOLIDAY WORK

Pemohon, : Disetujui Oleh, :

Nama : ______________________ Nama : ______________________

Jabatan : ______________________ Jabatan : ______________________

1. Hari, Tanggal & Waktu :

2. Lokasi Pekerjaan :
3. Aktivitas Pekerjaan :

4. Jenis Material :

5. Penanggungjawab :
6. No. Telefon :
7. Data Pekerja :
(Nama & Jabatan)

Disetujui Oleh,
EHS O&M PT. PLN (Persero) Pembangkitan Tanjung Jati B

K3L

* Overtime : di atas jam 17.00 wib dan di hari libur

* Lampiran berupa foto kopi KTP/SIM yang asih berlaku
 APPENDIX-7

Ref.No :
SC-WME JOINT OPERATION ( 'SCJO" )
Date :

MAJOR TOOLS & EQUIPMENT SECURITY GATE ENTRY

This is a list of Major tools and equipment which the Company/Contractor concerned wishes to remove from site and a later date

Requeste:
(Name of Company/Contractor) ( Name of Responsible Person ) Position :

METHOD OF ENTRY INTO THE PROJECT SITE : Trailer Truck/Truck/Pick Up

Others (specify) : ____________________________________

Driver's Name : _______________________ Vehicle Police No. : ____________________________________

DATE AND ESTIMATED DURATION ON THE PROJECT SITE

Date : _______________________ Expected Duration : _________________________________

NOTE : - Regular Entry hours on Mondays thru Fridays 08.00 - 17.00 WIB
- Saturdays 08.00 - 12.00 WIB

Quantity
Item
Description of Tool/Equipment Unit Company Equipment No./Ownership No.
No. In Number In Word (Say)

Aknowledged by NPN (SS-911) SECURITY CHECK AT MAIN GATE UPON ACTUAL ARRIVAL ON THE
PROJECT SITE
DATE : _________________ TIME :_____________
SIGNATURE : ____________________________________
FULL NAME : ____________________________________

(Name) DOCUMENT DISTRIBUTION

Position : ______________________________________ 1. ORIGINAL : Company/Contractor

2. COPY-1 : NPN (SS-911) Site Office
Date : ________________ Time : ________________
APPENDIX-10

SC-WME JOINT OPERATION ( 'SCJO" ) Ref.No :

Date :

MATERIAL GATE PASS (Via - MRR Process)

Please note that all materials entered onto the site via MRR process (Onshore or Offshore) cannot be removed from the Project Site - Until the
supporting documentation such as Master List/Packing Lists is attached* and signed off by an SCJO Site General Manger and CJP Director

Requested b: Verified By : _______________________________

(Name of Company/Contractor) (Name of Responsible Project Participants)

_______________________________
( Name of Responsible Person ) ( Name of Responsible Person )

Position : ______________________ Position : ______________________

METHOD OF REMOVAL FROM PROJECT SITE : Trailer Truck/Truck/Pick Up

Others (specify) : ____________________________________

Driver's Name : _______________________ Vehicle Police No. : ____________________________________

DATE AND ESTIMATED TIME OF REMOVAL FROM PROJECT SITE

Date : _______________________ Time : _________________________________

NOTE : - Regular removal hours on Mondays thru Fridays 08.00 - 17.00 WIB
- Saturdays 08.00 - 12.00 WIB

Quantity
Item No. Description of Materials / Equipment Unit Reason for Removal
In Number In Word (Say)

Acknowledged by:
Approved by SCJO Approved by CJP
PT. Nawakara Perkasa Nusantara (SS-911)

(Name) (Name) (Name)

Position : ___________________________ Position : _________________________ Position : _________________________

SCJO Ref.No. : _________________ CJP Ref.No. : _________________ Date : ________________

Date: ______________ Date: ______________ Time : ________________

SECURITY CHECK AT MAIN GATE UPON ACTUAL REMOVAL FROM

DOCUMENT DISTRIBUTION
SITE

DATE : _________________ TIME :_____________ 1. ORIGINAL : SCJO

SIGNATURE : ____________________________________ 2. COPY-1 : CJP
FULL NAME : ____________________________________ 3. COPY-2 : Contractor
Note: Valid by Company Stamp and Loading Forms 4. COPY-3 : PT. NPN Office
APPENDIX-10
*2 sets of attachment (plus photo of materials)
SC-WME JOINT OPERATION ( 'SCJO" ) Ref. No. :

Date :

MATERIAL / EQUIPMENT GATE PASS

Requested b: Verified By : _______________________________
(Name of Company/Contractor) (Name of Responsible Main Contractor)

_______________________________
( Name of Responsible Person ) ( Name of Responsible Person )

Position : ______________________ Position : ______________________

METHOD OF REMOVAL FROM PROJECT SITE : Trailer Truck/Truck/Pick Up

Others (specify) : ____________________________________

Driver's Name : _______________________ Vehicle Police No. : ____________________________________

DATE AND ESTIMATED TIME OF REMOVAL FROM PROJECT SITE

Date : _______________________ Time : _________________________________

NOTE : - Regular removal hours on Mondays thru Fridays 08.00 - 17.00 WIB
- Saturdays 08.00 - 12.00 WIB

Quantity
Item No. Description of Materials / Equipment Unit In Word Reason for Removal
In Number
(Say)

Approved by SCJO Aknowledged by PT. Nawakara Perkasa Nusantara (SS-911)

(Name) (Name)
Position : ___________________________
Position : ______________________________________

SCJO Ref.No. : _________________ Date: ______________ Date : ________________Time : ________________

SECURITY CHECK AT MAIN GATE UPON ACTUAL REMOVAL FROM

DOCUMENT DISTRIBUTION
SITE

DATE : _________________ TIME :_____________ 1. ORIGINAL : PT. NPN Office

SIGNATURE : ____________________________________ 2. COPY-1 : SCJO
FULL NAME : ____________________________________ 3. COPY-2 : Contractor

Note: Valid by Company Stamp and Loading Forms

 APPENDIX-11

Ref. No. : /NPN/XII/2011

To: SC-WME JOINT OPERATION ( "SCJO" ) Date : 14-Dec-11

CONTRACTOR LOADING FORM

Name of Contractor : PT. NPN SS-911
Person in Charge : Alexander Boy
Position : Site Manager

(1) LOADING SCHEDULE

Day :

Date : ……..Desember 2011

Time : 08.00 - 17.00 WIB

(2) LOADING LOCATION

Location : PT. NPN SS-911

(Specify in detail)

(3) TRANSPORTING VEHICLE DATA

Vehicle Type : _ Truk Police Number : __ H 1455 ZH

Driver's Name : _ Sumawi : ______________________________

(4) MATERIALS TO BE LOADED

No Description of materials Unit Quantity Reason of Removal

In Number In Word (Say)

1 AC UNIT PANASONIC unit 1 one

2 AC UNIT NATIONAL unit 1 one Donate to POLRES JEPARA

NOTES:

Requested by, SECURITY CHECK , ( LOADING POINT /LOCATION )

Name : Lukas Triyunanto Name :
Position : Staff Position :
Date : 14-Dec-11 Date :
Sign : Sign :

Note : Valid by Company Stamp

 APPENDIX-11

Ref. No. : /XII/2011

To: SC-WME JOINT OPERATION ( "SCJO" ) Date : 29-Dec-11

CONTRACTOR LOADING FORM

Name of Contractor :
Person in Charge :
Position :

(1) LOADING SCHEDULE

Day :

Date : ……..December 2011

Time : 08.00 - 17.00 WIB

(2) LOADING LOCATION

Location : Indomix plant, Truba Lay down

(Specify in detail)

(3) TRANSPORTING VEHICLE DATA

Vehicle Type : _ Truck Police Number : ______________________________

Driver's Name : ______________________________ : ______________________________

(4) MATERIALS TO BE LOADED

No Description of materials Unit Quantity Reason of Removal

In Number In Word (Say)

1 H-Beam 20x20x600 cm unit 15 fifteen

2 Plate 20x600 cm unit 20 twenty Sumbangan ke pemakaman pakis
3 BRC unit 35 thirtyfive aji & Lap. Tennis jl. Pemuda Jepara
4 Pipe support unit 35 thirtyfive

NOTES:

Requested by, SECURITY CHECK , ( LOADING POINT /LOCATION )

Name : Name :
Position : Position :
Date : 29-Dec-11 Date :
Sign : Sign :

Note : Valid by Company Stamp