No.

:
REPUBLIK INDONESIA
KEMENTERIAN PERTANIAN
BADAN KARANTINA PERTANIAN
KT - 12

SERTIFIKAT KESEHATAN TUMBUHAN ANTAR AREA

Nomor 2021.2.1005.0.K12.K.000046

Berdasarkan Undang-Undang Nomor 21 Tahun 2019 tentang Karantina Hewan, Ikan, dan
Tumbuhan serta hasil tindakan karantina tumbuhan, menyatakan bahwa media pembawa
tersebut di bawah ini:

1. Nama umum/dagang/kode HS: KELAPA ..................................................................................................

BULAT
2. Cocos nucifera
Nama ilmiah**): ...........................................................................................................................
3. Bentuk dan jumlah): Buah ....................................................................................................................
150.000 KILOGRAM;
4. Bahan pembungkus/kemasan: UNPACKED ....................................................................................................
OR UNPACKAGED
5. Tanda/merek pada pembungkus/kemasan: -................................................................................
6. Jumlah dan nomor peti kemas**): ...............................................................................................
==========
7. Nama dan alamat pengirim: ........................................................................................................
H Ambo Tang
.....................................................................................................................................................
Muara Sabak
.....................................................................................................................................................
8. Nama dan alamat penerima: ......................................................................................................
Bujang
.....................................................................................................................................................
Kuala Gaung
.....................................................................................................................................................
9. Tujuan pengeluaran: 3-BAHAN ....................................................................................................................
BAKU
10. Area asal dan tempat pengeluaran: KABUPATEN ...........................................................................................
TANJUNG JABUNG TIMUR / MUARA SABAK

11. Area tujuan dan tempat pemasukan: KABUPATEN ..........................................................................................

12. Jenis dan nama alat angkut: KLM
13. Tanggal berangkat: 01
INDRAGIRI HILIR / KUALA GAUNG
.......................................................................................................
PESONA SAKTI/-
.....................................................................................................................
AGUSTUS 2021

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: MUARA

.......................................
SABAK
Pada tanggal: 31 JULI 2021
.......................................
Pejabat Karantina Tumbuhan

.............................................................
SUPRAYITNO
NIP.......................................................
198104132006041003

*) Diisi bila perlu dan/atau memungkinkan.

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