‘Surat Keputusan Kepala Badan Pengendalian Nomar Dampak Lingkungan 802 0000058 No, Kop. 02/Bapedali0o/1995 a DOKUMEN LIMBAH B3. Tangoal 5 September 1985 tin depen bas Sucks ie (HAZARDOUS WASTE MANIFEST) [TBAGIAN YANG HARUM Di OLEH PENGHASILIPENOUMPUL IMBAN 03 (THis SECTION BE COMPLETED BY THE GENERATONCOLLECTOR T. Nema dan alomel Porvsahean Pergheal/ pengunpar 7 Lokes| pervaten tla berbede del Slamat porveaheen (Shiement location 7 Limbah 03 (GaneratorCalaeter* name and malling address): ‘diorant rom malig xdsross) Tops! Fax: 3, Nemor penghal (Generator reghiveton No) 7 Dain Pengiiman Linbah 83 ehpping descrpton 7 A Jone tinben 83 ‘8 Nama Tahnik bla ada © Karakterisk bah 0. Kode timbah 83 E: Kode UNINA | (Prisca State) Cohaical nemw it applicable); (Hazerd cess); (Hazard wesie code) (ONINA code) \ y L , | 7 Kelonpek Kenasan © Batvan varan (Unk Hula komanan T Kamat (Conan (rectig Gr) Bera (ghd ie {Qianty oF Packages): were) : A els Tp) lel (voume) (Aiuto! erred a nae! le era No. ro Wot) anganey Khuave dan kelerangan tambahan AVON Ad a nsormavory 1 "F NomorWlopon yong dapat dlaibungl dalam Foadean darvral Lo) Emorgoney reaparee contact Prion NO. x Pengumpul (Collector) / Pengolah (Processor) / Pemaniaat Gian har deel et peers reenter tae on cna dra rw arn perenrte ated ipiunyameneceer ‘Snes gt ye fa a Fara ten arog Re rea TRE an AG Farias enon tar erm ag et one ae weersae seer ca isa fe por enon es been ene tated nd tn raion fortrenaport | oF international ‘12, Tanggal / (Data) | 13: Nava del lr peruse pergengtitan cafe Saneil (apace Regiarton He MS Tnaseivneono'ond caress" PE BAGUggRON cas Te MORRO Roedarcan (veo loon) SA 0 DESALEBAREONG HE, #70 | amor tuck (rok No) 14.Nreriephoe (Prone no Name hapl (snp Nor) 1: Nomer Fax (Fave No) [eh penganghuten (Shiaping Permit) 50 Nae (ame Bebe (Te: er) it 2 testa ina) {5 Wma dan ala porczaoan ponganbtaah dt Bs SS 1-76 Nor Panataran Spada (Bupedal Regisvaten No) 1. (anspor tame nd adsres) 47, anton kencaraan (erste tray): Nemor ruc (ras) 14 Nemrwlaphane (ehene No): Nam Kapa (prea) ta.Nemor rar fas aye! i Sianeli eager 18: Nar ame] TB: Tonaa npn ipo) ant 7) ee aaa oan eel ; a toawaiee wan 9K aa alana poratn pargmnahlanWrbak BF “1 Norar Pandata Bape apeda Rogalon No) C. (Transporter namo and addres) 17, Identtas kendaraan | nt Identity); 18, Nomor Fax. (Fax. NO u Perm H t 19, Tanda iF Targge! pyrgergiuten (Shinpiy dete 18. Name (Name), tangan (Signature) 22. Tange! tanda iangan (Sign dete) “GAGIAN YANG HARUS DILENGKAP] OLEH PERUSAHAAN PENGOLAN PENGUMPUL / PEMANFAAT LIMBAN BS (THIS SECTION MUST BE COMPLETED BY THE PROCESSOR | COLLECTOR / EXPLOITER) 25, Narra den alamat porsehaan Pangolan/ Pengumpul/Pervaiast __2¢,_ Nomar wlonon Phone No 39 Procstor/Coletr ote’ Neme and eceess): 38, Nomor Fx fax No) nee ieee es 7) Nome Pecdatran Bepeda (Bape! Rereraton Ne): ‘Pernjaiaan Pewsshean Pengunpd ero be 63 Deg lene arya ney eh ranean tra 3 eoes [hinlen seperttraebut dates dan bahwe inbah tereosut akan drones eval dengan Parauran Perarinah Rata PeratranInienasina ‘concen ifn etd sn eno ce son 0 oot halt wi be procoased ‘rtm fo GON 27, Name ere): 28. Tanda tengen (Signature) : 8. Jabatan (Title) ‘30. Tanogal / (Date) : jaan ketdakseavslen Tpetelan Glonaiee, Imbah yong Gwabulkan bdak memeruhi syaral eehingga salanjuTiye akan Girambalkan Kepada perusanaen poaroct inn Sree men eee arometanias' nx tang cessed onde os etoved tote Goneioy Reciew ace i Ghace polar (etsy ferret | ttl el etoen 7 | 3s tangas Pongenbanen(teurran Ono) 33 Nana Perdehen Sopsil (Sapo eg, No): 38 Tere angen roeenser/Colager Snay) *) Coret yang tidak peru (Cross Out where not Applicable) “Guinan 3 Perinooel nuk Pengnasl (Wau) | i Proscar ConSurat Kesituson Kepale Bgdan Pengendalan Dampak \ingkungen No. Kep, p2/Bapedavag/i995 Nomar 802 9000058 DOKUMEN LIMBAH B3 ‘Tangga! §\September 1995 Dis dengan hur etek da (BAZAROOUS WASTE MANIFEST) Bock AGIAN YANG WARUS DIL (OLEH PENGHASILPENGUMPUL LIMBAH B3 (THis SECTION BE COMPLETED BY THE GENERATORCOLLECTOR) ¥ Nama dan lama Pousahaan Penghwll/pengumput Thai x bated i vor peuahue (Soman uewor “iba 89 (GanwraterColeetor*name and maling aero): xy z ewer wee HWeusttial Ker ' Grae i ' als, Bui ( “aE. Telp, [Fax 3. Nomor pesghaai (Garersarrapavaton No) 4 Daia Peroitman Linbah Bi (ehipping doserbteny A Joris imban'83 B.Nama Tehnik bla aca C.Keralteitkimbah 0, Kodo imbah 83 Kode UNA (Prisca! State) (Rehricalnemw i applicable): (Hezard class): (Hazard waste.code)!—— (UNINA cod) fadat Hain mag Aigo lip ORC aed F K@bmpok Kamasen Human kenasan 1. Kemasan Container (Peckng Group) + (auanty of Packages) Nomor (40) inti dons (ye) No. Prof Ws oni ha (Scoot handing hetuctn and ededonal infomation)? C)iidcl ean _A\ . 7, Noinorwepon yarg capat eihebdhgl dairy Kencnon carat? 0676 #929 1000) (Emergeray reapanee centect Phorm No): ne jan penganakuion Ke (Shipp purpose fo Pongumpul(Golectoy /Pengala (Precassor)/ Porenteat (pica sn Nota | Jka pengis formula junpul imbah/83 maka setuthan name perahaallimoah yanallmeahnys akan dl angie Soka iat yang km gorheat ko pengp (faring a ron Coleco nao traranosunshed wr topes apy ene coxmer svt oy He gree" tothe cotec | Perryataan Perusehoan penghesteargumpu imbah 65. dangar iri saya menyelakan bahwo imbah B3 yen alkrim sesel dendan parnclen pada d Yong erett can, sr choras ey doer lee andlor ueacaar ba uno arghtoy la ye, soa cargenPeraren Pare Paranoid (ProvscerCoectorcovieatan’ har by ovata sores ef O8 iy cess ave oy ne pepe anppeg deere ard [ppt pa ele eh isle as adh peel Naa cL | MIEN eoMuaTion [TH SOaaLTHAL fc. |e Tame Oom \GIAN YANG HARUS DI LENGKAPI OLEH PERUS/ 413, Nama den elamat parusshaan penganakutar A. (Transporter name and address): PT. BAG! ENE ANGI naa 3 (Ts SECTION MUST aE COMPLETED BY Te TRANSPORTER) | {8 Nome Pendata‘an Bapedal @anadal Rooitaion No): IKSES. enti Kendarean(vehile Kent), “LF SUTAMINO. BDESA LEBAKSQNO. KEC, Pt NomorGuek (Tuck Nay > 3 a 14, Nomor telephone (Phone no.) 121. Nama kapal (Ship Neme) ToT x 15. Nomor Fax, (Fax, No.) a izin pengangkutan (Shipning Permit) : 18, Nome (Name): 7 7 san GaN)? | 20. vetatan (THe) 2] eee eatin (pg Sa)? Udin Cotar 32 Tear nar an gt ane sana shear ee 75. Nomor Pendaflaran Sapadal (aapedal Regavaton No) 5 anspoternamé ond odes) "> 17), enitesKendaran (vehi erty) x Nomor rk (Tuek No) : 14, None teleshane Phone No} Name Kopel (shipnama) 2 45. Nomor Fax (Faso) L Ieinpangengln (Shipirg Permit 18, jeme (Nome) 10. Tenda angen (Sigvatire)? | 20. Jobatan (Tilo): [2k Far perenne (png dom) 22 Tw rd tangent: 73, Name dan elamal perusahaan pengangkvtan jinbah 83 Toro PancfranBapedl (Banodol Relator a) Tancpotor name an Nas P Wonton toraeeen ence beni: © ransoorornene ord ede) ren Nomor truck (Truck No, 1s Homer woprone fone Ho) tara ao (hp rar 48 Nome 18. Nar (va): 7f.Tansa organ (Seura): | 20 Jobin (TH 'BAGIAN YANG HARUS DILENGKAP! OLEH PERUSAHAAN PENGOLAH PENGUMPUL/ PEMANFAAT LIMBAH 83 "(THIS SECTION MUST BE COMPLETED BY THE PROCESSOR J COLLECTOR | EXPLOITER). | Pengumpul /Pemanteat 24, Nomor telepon (Phone No.) : is ae 26. Nomor Pencfa oe Pemyaiaan Permataas Pong nar "B97 Dengan Iniaara meryolakan bohviaseja lah manana Sere as ‘rheopon teeter tas ss tamerioaese Sets ess eee herotanh i al Peat nee ‘arteation ‘I hare by declare that 1 ali lee eile ‘ccorsing fo GOI or nteretona “27, Name (Neme) : ra By ‘Tanda tangan (Signature) = a et ter = Farag (Bate) = cea ie seme ore a Soa be oa ‘4, Alasan penolakan (Reavon. yethon) ternal] ye ies torscntatanteetapesonn 31, Nomor Pendataren Bayodal Bapoda eg, NO) i 38, Tanda tangon (roceccor Sehchvo) *} Cofet yang tidak peru (Cross Out where not Anplcable) "[ setnana forest Menai a BAPEDAC 1 Cony? | Froaver NatoNomat Boz 0000056 Dil dengan huruf eal dar (HAZARDOUS WASTE MANIFEST) ‘Surat Keputusan Kepala Badan Pengendalian Dampok Lingkungan No. Keo. 02/Bapeda/09/1905 DOKUMEN LIMBAH B3 Tanggal 5'September 1995 TBAGIAN YANG HARUS DIL (OLEH PENCHASILPENGUMPUL LINBAH 0a (Vis SECTION RE COMPLI EE CBURATORDULECTOR 1 Nova dan slomat Pou mnghasl/ penguirpur T Lakes! pamusion bis ere de der alana perusahean (Stomert locaton imbah B9 (Generate name ard malig oddrestl: fern tem mollng address) wy (Lag: TP. pick {Us (rial GUA 0 abet Ga Yon Ste wvel prone (Phone 19.) 16, Nomo: Fax. (rex, No) (Emergency response contact Phome No.) 3 Tujuen panpangkulan ke (Shiping purpoee Te) Chien Note: dn pargia formyl adwan pongumpal moan B3 me ‘dakumen Iba yang ohm gengneel ke pengumpu (Ue party feng thi tom a fra CoNegt, a te Iranapostec hinlahed wih ho eaporss lo eapy of he document aon! ty goreraiorb te clacte}" rcalayPetanoanfanghanargunpu tray By; Sorgar Fama Tenyanan twa ira Byung Gr van Gaga pain pan ata win BRD] Yara dala, we duara ey doo oe gor deumendtan a sh argu lal oe venue gen Pfalun Pana fi eran Maras | "Proszeronae’ sation Thy cool one sha conden a acy cc tor te wept pp tenor on hor ven ed obled ed wo ea nd nag highway ascarng GOL ralne Roguaendy “3: Noms din slamat perusahaon pengargktan 1X: Trntpartor nome and adgreta): FT. BASU Top Foe ee 4. Dava Pergirmen Limbah B3 (shipping description) ASeto img ss = Anhetenac sles C.Kerakerat noah. 0, Kode Imbans9 ade UNA (elds) rata norm apeicable): "Pew de) Noreen oS, teint, tor koutominner lee Av (Oca FT kaogpor koran Sauna than (Oso a rth lonasen Tirana Conan (eeolha Gein Beet a an iBianiyerevcaces); [ee Nomar) | ore in vote): 71.8 eg c ey! ‘5, Kotarengen lambahan untuk imbeh BS yang tereebut dates th (saat esos rh odo) No Poon #: ‘6. RevUls] perengahan khuaus don kelerangan tambehan ’ eee (Spesial handing inatruction and addeianal nformation) : GLINAECN aly y 7 Naor open yrs tal cb aes acon ar eT TaD ERT me Bin Identitae kenderaan (Vehiele 78. Name (Ramey? Icanttas kondaraan (Vehicle s Noreor tusk (Truck Pengimpul (Colecior|/ Pengclah (proeaster)/Pemanfoat (Exploler? ri imbahyyang imbaniya an a aa aa eran tang ea oan wait lel ean wana ‘Nomar Pendafiaran Bapedal (Bapecal Fens) Ine verte woe wate wl be /Regiatration No)? nd aera) 14, Nomertelephana (Phone No) 15, Noor Fax (Fox. No) ©. Mranspoter name 14, Nomor talaphone (Phone No,) ‘Nama Kepal hip namo): ; 1. Name Fox (rox Na) 12h bergen a 76: Name (Nome) Te, Tanda argon (Sigratire)? | 20, Jabatan (Tit) 1S aris ar Sis oon PUnpoCaRGh Dah 76 Nesror Papcatran Bapaaal Tage 17. \gontitas kendaraan (Vehicle | ‘Nomor nik (Truck No.) 48, Name (Name) Cnittren rseot ean ‘one bare Stardng 6 Gel ara Ta 431. denis imoah (Type of waste): 52, Jumleh (Quartty) AGIAN YANG HARUS DLENGKAPI OLEN PERUSAHAAN PENGOLAH PENGUNEUL a 3. Nara dan alamal perusahaan Pangolh/ Peng » 1. io 8 Pracessr/ Glaser” Bote ecaunel Pngaerarta ray 09 Coren see goryaaken baa re imeah oct ahd Boo i vats rod oom rataan al anata, Ti perghaai inet Oacepancy noucaton: the folowng 39, Nomer Pendattaran Bapedal (Bapedal Reg. No) 18, Tanda targan (Signature) {CTION MUST BE COMPLETED BY THE PROCESSOR / COLLECTOR / 24, we Tfeecina!: Ne ferrobutekan ssreceeeasua dengan Paratutan Panaiian ims *] Gore yang tcak peru (Cross Out where not AppicablSurat Keputusan Kopala Baden Pongandatan Waren Dampak Linglungon . No. Kop .02/Bapedal/09/1995 802 0000056 ; : DOKUMEN LIMBAH B3.__ uiapcos 8 epee 1096 sda (HAZARDOUS WASTE MANIFEST) dengan hr cea tan cen aaa eT TBA (ETON CD THe ERA TOREOTLEC rong! ‘pernuaten bile berbeda def iamal perveshaan (SNpment locaton if ‘Umbah 23 /Generaov/Oolecto” name and mi adorean)! ino trom meling edtéres Tos Pi Trip. Po 3. Noor penghanl (Generator gation No 7Data Pengriman Lnboh BS (appng A denis moan 83 Oe rae Se Krahn bah 0, Kode bah 83 Kado UNA ei) ((Tohnleal narw it appionble) | (Hanerd cleas) | (Hoxerd waate 00) / (UNMNA code) 1 | Ketompok Kemasan Ba rn Unb He umlah kamaoan 1. Kemesan (Container) | (Packing Grown), Borat (Quantity of Packagoa) : ‘Nomor (No) 71) Ry" Jenis: ) Iw (vou) ci ' Keterangan imibohan nik Iban BS yang tenable (Acaore! eeverotana for mare! ted above | No POM Wp |e lc peeroey ain a age EST ‘ metruction ard ediitional Information) ! 7 oar telepon yang dapat dihubunol dalam keadaan darvral | Mt 1 (femorgorey reapenive conlaa! Phone NO 1 7 Tujum pengargkuten ke (Shipping purpose fa) snGUMpU (Ooledtor) 7 Cr 97 No peg orl agua erga r roah 83 rok buen pana prota nba yoy nba Soe mines sara enunes iran yg orm pong ke BengJ™9u he arty ay nine ‘orapones Anhed uch he ayare apenas ere Train Peon ranbawa on Ha ee Se shanks phan joan ys al ru Pr Pa no rar {irodsrodnae frien’ Tham by dre alcove ‘rote id i conga ww sera Pn tre 8 roe as ame (ve) ca tengan Tt Te Name (ame) ‘GuTenee reer Serene) | 1 TE Yogi a0) 'GAGIAN YANO HARUS OI LENGRAP OLEH PERUSAPARN PENGANGRUT LINBAN|B9 TH8 SEOTION NUST BE COMPLETED BY TH 7S, Name don alam pervshesn perganghuth JaRS@RBS 18 NomerPencataan Sapedel(2onedel Reglraton No A. (ranparter rare end ectess| "FF BAGUBMADRGUKSES Identias Kendaraan (Vetice erty) Lt, SUTAM NO. BDESA LEBAKSONO- KEC AB, MOJOKERTO 16. Nomer telephone (hone no.) |_15.Nemar Fax. (Fox. No Nomor ick (Truck No.) : Nama kapa) (Ship Narr) tain pengangkutan (@Neping TE. Name (ame) Tabatan (Tie) Zi aga pepuegan REN ea] 2, Tegal mea (i) 1: Nara da slant peruse pore ono Fancafaren Bapecal Gopal ; Diener mae a ware Ge 15, dentin Kencersan Voice eth) Nomor ek Cruse No} 14 Nomor leone (Phone No): Name Kepa (ripneme) 15: None Pot (roe No) [onpengengtn (Sp *E Name (Nar) +B, Tondatargan Senate) | 20 Jbeion (Te) TS Nas en Sa pernatn engenghiton Irian TE Won Fencataran Bapecalpadel Regiaon oy: hee 47, lente engereen Vane Cont): Nonor re se No} i 1 Nome tle (hone Hod: Name Kepa enpmeme): {5 Nomot Fox fae Nop: {nrpengangltian (hgping Bei: 1: Name Qiao) 18. Tarda angen Strain): | 20-dabatan (Tl) 'BAGIAN YANG HARUS DILENGKAPI OLEH PERUSAHAAN PENGOLAH PENGUMPUL/ PEMANFAAT LI TP SEE TOW MUST Be CoML TELL E Te re sNe C015 Oe 7A. Narva dan alamat parusahaan Pergolah/ Pergumpul /Pemanfeat 24 Nomor telepon (Phone limbbah 83 (Processor / Collector /| "Name and address): 26. Nomor Fax. (Fax, No.) cs 7 ase ea a erg 21. Jenis imbah (Type of waste) akan (Reason se ee: 32. Sumish (Quantiy m rorcepalen (ete On) 33, Nomer Pendetaren Bapedal (Bapodal Reg. No) tanga Processor Covet gai) *] Corel yang tidak peru (Cross Out whore nat Applcable)Surat Koputusan Kepaia Sedan Pengendalian Noner (oe gis al 802 900061 No Keps02/eapecavoar1995 DOKUMEN LIMBAH B3 Tanggal September 1098 i desockcnl tar (HAZARDOUS WASTE MANIFEST) (CRAGIAN YANG WARUS Oi OLEH PENGHASILPENGUNPUL UMGAN 63 (7H SECTION BE CONBLETRO RY The TENERATORICOLIECTOR) 1 Nene di lana ar ahaa ponguroul 2 Lola pera Ba bran strat perdahany [int cnvon Unban 83 (GeneratarColectr name and mating dross): Snort hom mating waereoe\ are fare Her PCMAG LS (reat i ‘ beak bot rere 2: Nor pengheel (Genet raor Ne) Data Ponatran Unban 83 hen denen] ‘A Rencfunnitis do _C-Karktrask bah 0, Kade inbah 3 6 Kado UNA abn ram faptcaba): (Hazard ass) (Hazard waste cass): luni eady f Airy fei inet Kcr ade ioe F, Kelorpek Keneson . Savon varon (Unto): | H. unish keesen Ty Reman (Corder) (Focing Got) Bra (i an (Glonay or actones Nomor i) \ tsa): I i seis 300) 5 orwgnfbahin unk ray BS yong iret das (adshiata osxrotans former! lve soar) Popa jas Bergeron Kut dn fetoregon tonbaTot (Sposa handing hetuston and eden Fiona tea ’ 7. Nana Teeponyeng dapat dbo cae Feofaen dora Taras 1000 (eroryen)roapatin Contre non NO) Tuan pengarokutan Fe (Shp purpose) engrpul(aleca) Pangaiah Prasassoy Poraniaat (pier? 7 Nite: 28)» labaten (Tite) aceon Wah Feoalah Caras, bah ang desbiian Wook era sara ssi raye coon ekoy herb Caner ogee ycaae va emt anak ory coed nosh cones Seeomres eee 21, denislimbah (Tyge of wast): ee 32 Jumlah (Quart)? 23! Nomor Pendataran Bapedl (Gapedal Reg. No): "Ore yane tak pe (Crome OU where not APPICaBIG)“SLE PENGHASILPENGUMPUL LIVBAN ha (8 SECTION BE COMPLETED BY Nil GENERATORCOLLEGTOR) Se Sea Pene shes perqurpuT 7 Loken eurusan Ye be-bada dar dial canaahean(3Npment cation mba 89 (Genera ‘nama nnd maling addres) Sree et eater Seana f LoriPickemneUm Tir! Cawwbior niet note “Tapia Vili cy : Nomorborahesl [Guneratorgliraton Wa) Tob /Fex Dina Porgin Unbah B3 epg deseo Aiea nah 83, Noma Tehink a ado . Karaka bah 0: Kod tbh 8 Moto UNA (Pisin! Stato) (Fehneal narnw Wfapplcable); (Hazard cast) (Hazard wasto code) {UNA coo) {er aca G9 aun 6 lod Ts Kernan (Cortaoor emer Way Jens Oe) Sewn hare (Un a Maan barren Bera oe {arty of Posh on iach 15_fe (Packing Group) rat Keputusnn Kejpala Badan Pengendalian Nonat Dampak UIngkungan {BDz on00059 No Kop, 02/Bnpedev/09/1905, ae DOKUMEN LIMBAH 83 18 September 1995 beeen ead (HAZARDOUS WASTE MANIFEST) [BAGIAN YANG RARUS OLE 2 7 nervin perangaran thom dan iwrenaNN AMDRNWN crc Ae (Bpeain handing htveton and addtional informa INGSGrt 7 aThvouglawor Ke tat Phan Na 7 Noinor weapon vara Go tore yang, a sebair re gongrast in yang rai ‘a Sta Sree chant state arrow eae! awa Bang Wr vos Govan pt pad ar ney oa ‘hawompre cc saree eerie werden co sacri nna | Sainiah Netw J pari! orm adniah parquet sega ail gran wlan eras has sfntm ela Pernyataan saa pa ya rani a, wre (ProduoerCalecto ve “TS, Nama sa olamatpervehannpengargivian Namr 7 Bopedel (DapodalRegheraven No k emt “Pr Bau {P: Nena tongarsen (voce \vapay) "°° 7 JL AUTAMING, BDA LUBARBONO nto, POND KERIO ae : Nomor io (Tuck Noy) ‘oe lat 14, Nomor telephone (Phone no, 032. Na Sig Si iS Nonorran roc hoy tent ei pengenigevan fone "Toro poegncan (vara oom) 2. vabatan (Tie) g BA Teg nd ryan ip et 2 Cont if, Nomor Pendaftaran Bapad TE Name (hime) 1 Cidin "B Nae da laa perceahaen erga ao 1, Manapertername and ares) | 47, antan renen (i s Nomer iui Naa Kagel | a) Nar dan oa ra 2 munworernam¢ ond saumy ee No.) 78, Na (te: 19, Tanda tangen (gnatur) : AGIAN YANG RARUS DILENGKAP! OLEH PERUSAHAAN PENGOLAH PENGUMPUL / PEIIAN! NTIS SECTION MUST SE COMPLETED BY THE PROCESSOR / COLLECTOR/ EXPLOITER) 7, Nema dan alanal pensahash Pergsiah/ Pengunpal/Pemanfeat _ 24.. Nom elepon (Phone No) sare Bs eater ‘Name and address); 25. Nomor Fax. (Fax. No.) nS 28. Noor Pe - = rb 89; Dargo mse meyataton Baie saya wish marine ine tnbah 69 Gergen on rere ee arden tog evren rena ot Fee sCutocore ahd bo be end qual ot wosld ae desorbed above bythe Gorarvor Eon a olin pean 28, Tafa angen (Signatr) 2B. dabotan (Tl)! 30, Tengael/ (Date) arta IeL 1 aay TSENG Tahaan raion TBS arg Sean ora Hal sage Sea unyaakan UKeTbaan Kees porishaan Fenhaniimes Bacepancy rtfcatn’ bo blest wes tor sealed Se wdlberouived ee Gana) een 31. Joris imbah (Type of waste): if ‘34. Alasen penolakan (Reason for rejection 32 Jumlah (Quanity): 38.Te n (Returned Date) 33. Nomar Pndatrn Bupa eed oo. No) 36, Tanda tangan | (ere Ce ‘Sigratyre) 7 io BAPEDAL( Coye oBAPEDL i al la‘Surat Koputuson = ) Kepola Bodon Pongondaton contain | DampakUngkungan Boz 9000059 : No. Kop, 02/Bapedav00/1095 DOKUMEN LIMBAH B: Tangaal 8 September 1905 (HAZARDOUS WASTE MANIFEST) |OTION BU COMPLEYRD BY Tia GRVERATORCOLLECTOR) Cll dengan hurut cota a Jak AGIAN YANG HARUS DILENORAP| OLEH PENONAGIL/PBNOUMPUL UMBAN 88 (Tl Ten carina TT penguno™ Totee prmatan ta bobeta dat urortoseeees pre {imnen 83 (GunertorGotector name ond moling adhoos): stare om naling wadro) n= Feore nen al ; re) ep.) Fae: Tovar progheal (Genero graven hoy abate Pengrinan Ubon BS [ang ousempTOn AOE nS Raa Tomko ©. Karaka imbah 0, Kade inbah 89 rte ‘enisoa Ser) {rotmtal vor tepptcele): —(Hanard ches), (aterd wane toon): “yuma, ‘Sat i of * rarest I Ke aot TEISORAN tanner @, Bowen aren Uno "7 rae (Con (Peeking Growp) Bora fala” Ton (Quanity of Packogou) : ie! wicvoume | 3 Kateraon tbanon Dv Tah OF yong lonebu dal 5 (Adon dreratans or mater te above) No, Pre Wp 6 Instruke! anan Khusus dan katerangan tambehan (Spesia! handing instruction and additional Information) T Noror lap yeng dapat dial clon oudaan dal THT 6300 1090 (Emopanchrepane crit Poave No) @ Tuluen perwenghten we (Ghlophe pupore fe) Penguimpul (Gollecor)/ Fengolah (Processor)/ Ferrarfoal (Expolor? Tainan Now Jie penal broul Femin parcuTpy TBO BD rave Bua De pnghael Imbah yaa InGenys aay agit ol wat npren asian seareel Benen fend te prof tnepty tha fom st Covet hans e Sepe nro maw o SeeezetTld ihe ens 6 ote aotmen snl by he generar nh oll Fe yn Perusahaan | jaal/pengampul imben BD deng yn inl saya ren ‘Dehwa limbeh B3 yang Gikirim seaual dengan | vlan | ‘dafar wlan Deku Penson er oor tr unr ca ia navn earner Penn ea ia rr a 3 a [pecircore mre fen eo mene a eaten Th, dabetan (Tite) fo] Se Teraael (oot); TGAGIAN YANG HARUS DI LENOKAPI OL {GANGNUT LIMBAN 83 (THI8 SECTION MUST BE COMPLETED BY ThE 13. Nora don elamot perusshean pengangiutan 6, Nomar Pendaftaran Bapedal (Boped Registration No.)= ‘A. (Transporter name and address) : PT. BAGI \OMBOKSES ‘17. Identites kendaraan (Venicie identity ) > SL SUTAMI NO ESA LEBAKSONO -KEC. Pu joente || rene et cra nh , 14 Noor elephone (Phoneno) : oat 4 Nama kapal (Sho Namo): 415, Nomor Fax (Fax NO} 200i tan ponganghutan (Sheng Perm): 18. Nome Wome) = 8. gy; | 2D. abatan THe): 7. arpa Soa a) | 12 Tangoaanda tng ign ct): Nomor Perdataran Sapedal Bapedal Registration No) nites Kendarsan (Vahlelo deny) Nomor tuck (Truck No) : ‘ 7 Tara ca lat pram sopra ot Bs 1B (Transporter name and addres): 14 Nomor telephone (Phone No): Nama Kapal (eh nama) : i 415 Nomor Fax. (Fax. No) 5 Ia pengangkutan (Shoping Permit): 48 Nar (Name) 79, Tends tangan (Sunature): | 29. cabatan (Tite) : 21. Trwalperaerahan Snore a) 22. Tenant tng (i 75: aria dan alma porusahaan pengangkatanWrbah BS 15, Naor Fordatiaran Sapadal(Bapedal Ragan No) AT. Identtae kendarsen (Vehicle dently): © (Transport name and addres) ‘aortas kan veh 14 Nomor telephone (Phone Ne): Nama Kapa (sho rare) 15 Nomor Far Par Wo) : {em pongonglstan (Shppng Pert) ‘16. Name (Neme) : 19. Tanda tangan (Signature) > 20. Jabatan (Titie) 21. Teragetpyogsogictan (Sheng dete: ' 122, Tangga tarde tangan (Sign dae) BAGIAN YANG HARUS DILENGKAP! OLEH PERUSAHAAN PENGOLAH PENGUMPUL / PEMANFAAT LIMBAH B3 (THIS SECTION MUST BE COMPLETED BY THE PROCESSOR | COLLECTOR / EXPLOITER) © ‘23, Nama dan siamat perusshaan Pengolah / Pengumoul/ Pemarfaat ‘24. Nomar talepon (Phone No.) f Ienboh 5 (ocecsor/Colacer/ Eater ‘Name and edaeas)* 28, Nome Fax (rae Na \ 4 Nor Peden nn om ain): SSS fare amor veneer aes puna ace EE Teac rst tans sv ance eco asa Bement i Nerve War) a, Tanda angen (Sgnfiro)’ 20, dabston (To) 30 nba Ba) | Ferrin aaTscnaan Wb spel Gara, bh arg daoblln ak manent esa shirgga sdajvHya oan AReBAIBan apodh peTraraah snes oe ce nerd ea Booty soomts mseaeaTounae vole cone i 1 Jens lnbah Type of west) 34 Alssan penolakan(Reasen for econ By Jumiah (Quantity) * 95 Tenggal Pengembalion (Returned Date) : 3) Nomar Pendataron Bapedal (Bopedal Rey No) $6. Tones tanger (Brocersor/Colotor Sinai) 7) Corel yang ‘dak ports (Cross Out where notApplicatle) “alinan 3 Pertingga! untuk Penghaal (Hila) Ry Copy Pradvsors Copy