LIST FORM INTERTEK POMALA

No

1 Test Kehalusan
2 Sieving Record -3mm
3 Daily Check Timbangan (Verifikasi Timbangan)
4 Status Sample At Oven
5 Daily Check Oven (Verifikasi Suhu Oven)
6 Re - Test Sample
7 Moisture TML
8 Moisture Content (MC)
9 Transportable Moisture Limit (TML)
10 Barging Report
11 Sampling Shipment
12 Sampling Dispatch And Receival
13 Dispatch Original
14 Pre Shipment Inspeksi
15 Stock Solar
16 Material IN
17 Material Out - Sampling
18 Material Out - Every Day
19 Tanda Terima
20 Prep Production Per Machine And Monitoring Of Pulverising Sample
21 Record Sample-Disposal
22
23
24
25
 TEST KEHALUSAN SAMPEL 200#

Prep Facility :
Client :
Dispatch No :
Job Number :
Number of Samples :
Job Number :

Berat Total % Kehalusan

Waktu Digiling Sieving
No Sample No. Halus (gr) Kasar (gr) Berat/gram A x 100% Keterangan
(menit) Oleh Oleh
A B A+B A+B
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20

Notes:
1. Test kehalusan sampel setiap 20 sample (1:20)
2. Berat sampel untuk test kehalusan minimum 30 gr
3. Nilai % kehalusan sampel adalah ≥ 95% - 100%
4. Apabila nilai % kehalusan sampel < 95%, maka sampel harus digiling ulang hingga mencapai kehalusan ≥ 95%

Diperiksa Oleh Disetujui Oleh

 SIEVING RECORD 3 mm

Prep Facility :
Client :
Dispatch No :
Job Number :
Number of Samples :
Job Number :

Berat Total % Kehalusan

No Sample No. Halus (gr) Kasar (gr) Berat/gram A x 100% Crusher Oleh Sieving Oleh Keterangan
A B A+B A+B
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20

Notes:
1. Record sieving 3 mm setiap 20 sample (1:20)
2 Nilai % sieving sampel adalah ≥ 95% - 100%
3 Apabila nilai % sieving sampel < 95%, maka sampel harus crusher ulang hingga mencapai kehalusan ≥ 95%

Diperiksa Oleh Disetujui Oleh

 VERIFIKASI TIMBANGAN
Merk/Name :
Serial No. :
Month/Bulan :

SHIFT-I SHIFT-II
Date 1.000 (gr) 2.000 (gr) 1.000 (gr) 2.000 (gr)
Staff KETERANGAN Staff KETERANGAN
I II III I II III I II III I II III

Diperiksa Oleh Disetujui Oleh

 STATUS SAMPLE AT OVEN
SAMPLE AT OVEN
No CLIENT VESSEL LOT IN OUT REMARKS
DATE TIME DATE TIME
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
 VERIFIKASI SUHU OVEN
SHIFT-I SHIFT-II
Date OVEN-I OVEN-II OVEN-I OVEN-II
Staff KETERANGAN Staff KETERANGAN
JAM SUHU (0C) JAM SUHU (0C) JAM SUHU (0C) JAM SUHU (0C)
01/09/12
02/09/12
03/09/12
04/09/12
05/09/12
06/09/12
07/09/12
08/09/12
09/09/12
10/09/12
11/09/12
12/09/12
13/09/12
14/09/12
15/09/12
16/09/12
17/09/12
18/09/12
19/09/12
20/09/12
21/09/12
22/09/12
23/09/12
24/09/12
25/09/12
26/09/12
27/09/12
28/09/12
29/09/12
30/09/12

Diperiksa Oleh Disetujui Oleh

 FORM RE-TEST SAMPLE
SAMPLE NO. REQUEST
No CLIENT NAME VESSEL NAME REMARK
FROM TO BY DATE

5
 MOISTURE CONTENT (TML)

Berat Sample :..............................gram

Weight Tray Weight Sample + Tray Weight Sample + Tray

Moisture Composit No. Tray
(gram) Wet/gram Wet/gram
MC ORI - A

MC ORI - B

MC ORI - C

Berat sample sebelum disizing :..............................gram

Weight Tray Weight Sample + Tray Weight Sample + Tray

Size No. Tray
(gram) Wet/gram Wet/gram
+7 mm

-7 mm

Berat sample setelah disizing :..............................gram

Prepared by,

(..................................)
 MOISTURE CONTENT
VESSEL :
CLIENT :
DRY WEIGHT DRY WEIGHT
WET
SUB NO WEIGHT WET WEIGHT
WEIGHT DRY WEIGHT DRY WEIGHT DRY WEIGHT DRY WEIGHT DRY WEIGHT DRY WEIGHT DRY WEIGHT DRY WEIGHT DRY WEIGHT

SAMPLE + SAMPLE SAMPLE + SAMPLE + SAMPLE + SAMPLE + SAMPLE + SAMPLE + SAMPLE + SAMPLE + SAMPLE +
LOT TRAY TRAY TRAY TRAY TRAY TRAY TRAY TRAY TRAY TRAY TRAY TRAY
( GRAM ) ( GRAM ) 21 JAM 23 JAM 25 JAM 27 JAM 29 JAM 31 JAM 33 JAM 35 JAM 37 JAM
 DATE:
JOB :
Y WEIGHT
DRY WEIGHT DRY WEIGHT

SAMPLE + SAMPLE +
TRAY TRAY
39 JAM 41 JAM
 TRANSPORTABLE MOISTURE LIMIT (TML)
STAGE I
INITIAL DIAMETER AFTER DROPPED WATER ADD CONE EXPANSION
No
(mm) (mm) (mm) (mm)
1
2
3
4
Average
STAGE II
INITIAL DIAMETER AFTER DROPPED WATER ADD CONE EXPANSION
No
(mm) (mm) (mm) (mm)
1
2
3
4
Average
STAGE III
INITIAL DIAMETER AFTER DROPPED WATER ADD CONE EXPANSION
No
(mm) (mm) (mm) (mm)
1
2
3
4
Average
STAGE IV
INITIAL DIAMETER AFTER DROPPED WATER ADD CONE EXPANSION
No
(mm) (mm) (mm) (mm)
1
2
3
4
Average
STAGE V
INITIAL DIAMETER AFTER DROPPED WATER ADD CONE EXPANSION
No
(mm) (mm) (mm) (mm)
1
2
3
4
Average
 BARGING REPORT
VESSEL NAME :
CLIENT NAME :
DATE LOADING :..................................
S/L F/L C/O QTY
No. TUG BOAT BARGE INC WEATHER REMARK
DATE HOUR DATE HOUR DATE HOUR (MT)
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
TOTAL MT
 SAMPLING SHIPMENT
LOT :
DATE :
VESSEL :
BARGE :

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20
1 2 3 4 5 6 7 8 9 10

21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40
11 12 13 14 15 16 17 18 19 20

41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60
21 22 23 24 25 26 27 28 29 30

61 62 63 64 65 66 67 68 69 70 71 72 73 74 75 76 77 78 79 80
31 32 33 34 35 36 37 38 39 40

81 82 83 84 85 86 87 88 89 90 91 92 93 94 95 96 97 98 99 100
41 42 43 44 45 46 47 48 49 50

101 102 103 104 105 106 107 108 109 110 111 112 113 114 115 116 117 118 119 120
51 52 53 54 55 56 57 58 59 60

121 122 123 124 125 126 127 128 129 130 131 132 133 134 135 136 137 138 139 140
61 62 63 64 65 66 67 68 69 70

REMARK: SHIFT 1 :
:
:

SHIFT 2 :
:
:
 SAMPLE DISPATCH AND RECEIVAL FORM
DATE : PLACE/ORIGIN :
JOB NO. : CLIENT :

SAMPLE CODE : SAMPLE CODE : SAMPLE CODE :

SAMPLE ID : SAMPLE ID : SAMPLE ID :
Bag No. Seal No. Type Of Sample REMARK Bag No. Seal No. Type Of Sample REMARK Bag No. Seal No. Type Of Sample REMARK
Sample Weight (Kg) Sample Weight (Kg) Sample Weight (Kg)

Sent By Received By

Name : Name :

Detail : Detail :

Note : Lembar asli supaya selalu dibawa oleh penerima, diserahkan bersama sample ke Laboratorium
 SAMPLE DISPATCH AND RECEIVAL FORM
DATE : PLACE/ORIGIN :
JOB NO. : CLIENT :
MV. :

SAMPLE SAMPLE SAMPLE

CODE : CODE : CODE :
SAMPLE ID : SAMPLE ID : SAMPLE ID :
Type Of Sample Type Of Sample Type Of Sample
Bag No. Seal No. Sample Weight (Kg) Bag No. Seal No. Sample Weight (Kg) Bag No. Seal No. Sample Weight (Kg)
Bag 1 Original Bag 16 Original Bag 31 Original
Bag 2 Original Bag 17 Original Bag 32 Original
Bag 3 Original Bag 18 Original Bag 33 Original
Bag 4 Original Bag 19 Original Bag 34 Original
Bag 5 Original Bag 20 Original Bag 35 Original
Bag 6 Original Bag 21 Original Bag 36 Original
Bag 7 Original Bag 22 Original Bag 37 Original
Bag 8 Original Bag 23 Original Bag 38 Original
Bag 9 Original Bag 24 Original Bag 39 Original
Bag 10 Original Bag 25 Original Bag 40 Original
Bag 11 Original Bag 26 Original Bag 41 Original
Bag 12 Original Bag 27 Original Bag 42 Original
Bag 13 Original Bag 28 Original Bag 43 Original
Bag 14 Original Bag 29 Original Bag 44 Original
Bag 15 Original Bag 30 Original Bag 45 Original

Sent By Received By

Name : Name :

Date : Date :

SAMPLE DISPATCH AND RECEIVAL FORM

DATE : PLACE/ORIGIN :
JOB NO. : CLIENT :
MV. :

SAMPLE SAMPLE
CODE : CODE :
SAMPLE ID : SAMPLE ID :
Type Of Sample Type Of Sample
Bag No. Seal No. Bag No. Seal No.
Sample Weight (Kg) Sample Weight (Kg)
Bag 46 Original Bag 61 Original
Bag 47 Original Bag 62 Original
Bag 48 Original Bag 63 Original
Bag 49 Original Bag 64 Original
Bag 50 Original Bag 65 Original
Bag 51 Original Bag 66 Original
Bag 52 Original Bag 67 Original
Bag 53 Original Bag 68 Original
Bag 54 Original Bag 69 Original
Bag 55 Original Bag 70 Original
Bag 56 Original Original
Bag 57 Original Original
Bag 58 Original Original
Bag 59 Original Original
Bag 60 Original Original

Sent By Received By
Name : Name :

Date : Date :
 Pemeliharaan Alat

Crusher - 10 mm crusher - 3 mm LM 2 (1) LM 2 (2) LM 5

No.
TGL KET TGL KET TGL KET TGL KET TGL KET
 PRE SHIPMENT INSPEKSI FORM
Informasi Umum

Inspector Bertugas

- Nama

- Posisi

- No Surat Tugas

Informasi Kontak On Site

- Nama

- Posisi

- Phone/FAX/dll

Informasi Inspeksi

Mulai Inspeksi (Tgl/Jam

Selesai Inspeksi (Tgl/Jam

Informasi Stockpile

Lokasi Stockpile

Stockpile Terpisah Secara Jelas?

Stockpile Beridentitas?

Bentuk Stockpile

Kontaminasi Material

Stockpile Foto

Top Size Material

Jumlah Stockpile yang di Sampling

(Estimasi quantity cargo)

Jumlah Sub Sample (LOT)

Jumlah Increment per LOT, berat per

Increment, berat per LOT

Apakah berat per Increment Seragam?

Sample moisture terpisah?

Sample size terpisah?

Alat sampling yang digunakan?

Apakah ada bantuan alat berat?

Kedalaman sampling pada stockpile

Pengamatan lain
 SKETSA STOCKPILE

Inspektor
 MATERIAL IN
Ship to:
PT. Intertek Utama Services - Kendari
Jl. woltermongensidi (Depan Polsek
Ranomeeto)
Kel Ranomeeto, Kec Ranomeeto, Kab. konsel
Kendari, Sulawesi Tenggara 93372
Indonesia
Telp: +624013005781

From Di Terima Oleh Intertek Jumlah

No. ITEM / Barang barang Unit Keterangan
Pengirim Courier / Ttd Tanggal Nama Penerima
1
2
3
4
5
6
7

10
11

12

13
14

15

16

17
 MATERIAL OUT - SAMPLING
Job - Lokasi :_________________

Leader :_________________

Khusus Segel
Ambil Dikembalikan Jumlah
Order - I Order - II Order - III
No. ITEM / Barang Keterangan
Dikemb
Tgl JML Tgl JML Diambil Start End Start End Start End
alikan

1 Security Seal

2 Lakban Intertek

3 Lakban Oven

4 Isolasi Intertek

5 Form Sampling shipment

6 Form Dispatch Sampling Original

7 Form Dispatch Sample Site To Kendari

8 Form Barging Report

9 Form chain of custody

10 Form submission

11 Form Sealing Packet Sample 200#

12 Surat Tanda Serah Terima

13 Flow Chart Kerja Sample

14 Assignment Letter

15 Karung

16 Plastik MC

17 Plastik GA

18 Plastik Besar

19 Scoop 125 D

20 Scoop 30 D

21 Scoop 15 D

22 Scoop 0,25 D

23 Scoop mixing

24 Kamera

25 P3K

26 Sieve 20 mm

27 Sieve 10 mm

28 Timbangan Portable

29 Capi - Pemisah

30 Cangkul

31 Meteran Jahit

32 Mesin Pres

33 Alumunium foil
Approve by,
34 Box sample

35 pulp sample
(______________)
 MATERIAL OUT - EVERY DAY
Ambil Dikembalikan Jumlah Khusus Segel
No. ITEM / Barang Dikemb Keterangan
Tgl Nama Tgl Nama Diambil alikan Start End

10

11

12

13

14

15

16

17

18

19

20

21

22

23

24

25

26

27

28

29

30

Approve by,
(______________)
 PT. Intertek Utama Services - Kendari
Jl. woltermongensidi (Depan Polsek Ranomeeto)
Kel Ranomeeto, Kec Ranomeeto, Kab. konsel
Kendari, Sulawesi Tenggara 93372
Indonesia
Contact Person: Jhonson Sinurat
Tel: +624013005781

TANDA TERIMA
Telah Diterima Dari :

Materi / Barang :

Tanggal Diterima :

Catatan :

Diserahkan Oleh, Diterima Oleh,

Nama: Nama:

PT. Intertek Utama Services - Kendari

Jl. woltermongensidi (Depan Polsek Ranomeeto)
Kel Ranomeeto, Kec Ranomeeto, Kab. konsel
Kendari, Sulawesi Tenggara 93372
Indonesia
Contact Person: Jhonson Sinurat
Tel: +624013005781

TANDA TERIMA
Telah Diterima Dari :

Materi / Barang :

Tanggal Diterima :

Catatan :

Diserahkan Oleh, Diterima Oleh,

Nama: Nama:
PREP PRODUCTION PER MACHINE AND MONITORING OF PULVERISING
SAMPLE

JOB NUMBER : DATE :

PULVELISER NUMBER :

SAMPLE NUMBER PULVERISED BY SAMPLE NUMBER PULVERISED BY

No. No.
NOMOR SAMPEL DIGILING OLEH NOMOR SAMPEL DIGILING OLEH

Note :* Test Kehalusan Sample

Checked By Approved By
 RECORD SAMPLE-DISPOSAL

SAMPLE
No. RECEIVED - DISPOSE - -10 mm -3mm 200# REMARK
CLIENT
DATE DATE LOT LOT LOT
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
 EXPENSE REPORT

DATE DETAIL OF EXPENSE (PURPOSE, STAFF OR OTHERS PRESENT) TOTAL EXPENSE

Prepared by:

LEADER I LEADER II

( ) ( )
 From Sealing Packa
Job No :
RECORD SEALING PACKET "200#"

NO DATE TIME PACKEGED BY SIGNED BY

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
 From Sealing Package Sample "200#"

D SEALING PACKET "200#"

SEAL NO
SEALED BY SAMPLE ID WEIGHT
(GEOCHEM PAKAGE)
 SEAL NO REMARK
(ALUMUNIUM PAKAGE)

FRM/PRE-15.REV.00

CHEKED BY APROVED BY