Instalasi Penyehatan Lingkungan Rumah Sakit

(IPLRS)
RSUD PARIAMAN
Jln. Prof. Yamin SH No. 5 Telp. (0751) 91118 – 91428 (Fax-Direktur)

PERMINTAAN PERBAIKAN
No : …… /IPL/…./2022
Pariaman,………………… 2022
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Kepada
Yth. Ka. IPLRS RSUD Pariaman

Dengan Hormat,
Bersama ini saya laporkan bahwa terdapat kerusakan di bagian / diruangan kami sbb:
1. _________________________________________________________________________
2. _________________________________________________________________________
3. _________________________________________________________________________
4. _________________________________________________________________________
5. _________________________________________________________________________

Ka. Sub. IRNA/IRJA/INST./ Bag

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=______________________=
Nip.
SERAH TERIMA
Instalasi Penyehatan Lingkungan

Hari / Tanggal : ________________________________________________________

Jenis Kegiatan :
__________________________________________________________________________
. __________________________________________________________________________
. __________________________________________________________________________
. __________________________________________________________________________

Analisa Kerusakan :
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________

Penggantian Suku Cadang :

1. _____________________ 6 ____________________11 _________________________
2. _____________________ 7 ____________________12 _________________________
3. _____________________ 8 ____________________13 _________________________
4. _____________________ 9 ____________________14 _________________________
5. _____________________ 10 ___________________15 _________________________

Pariaman, ……………… 2022

Diterima baik oleh Teknisi Mengetahui
Ka.Sub.IRNA/IRJA/INST/ Bag Ka. IPLRS RSUD Pariaman
…………………………………

=__________________= =___________________= = Yanseven Syaryetty,ST =

Nip. Nip. Nip. 196501071988032002