PENGADAAN BMHP PUSKESMAS SUKODONO- LUMAJANG

Harga Penawaran JUMLAH

No. Nama Barang QUANTITY
Non PPN (Rp) ( Rp. )
1 Alkohol 70% 1 L 20 Botol 27,000 540,000
2 Celluloid strip 1 box 100,000 100,000
3 Dental matrix spring clip 1 box 145,000 145,000
4 Dental Microbrush 2 box 20,000 40,000
5 Jarum Jahit kulit GT 7 5 set = 12 pcs 16,000 80,000
6 Jarum Jahit kulit GT 8 5 set = 12 pcs 16,000 80,000
7 Jarum Jahit kulit GT 9 5 set = 12 pcs 16,000 80,000
8 Jarum Jahit otot GR 7 5 set = 12 pcs 15,500 77,500
9 Jarum Jahit otot GR 8 5 set = 12 pcs 15,500 77,500
10 Jarum Jahit otot GR 9 5 set = 12 pcs 15,500 77,500
11 Stik Asam Urat easytouch (Silpa) 50 botol 97,900 4,895,000
12 Stik Kolesterol easytouch (Silpa) 100 botol 150,000 15,000,000
13 Stik gula darah easytouch (Silpa) 50 botol 84,500 4,225,000
14 Stik HB Mission (Silpa) 82 box 445,000 36,490,000
15 Urine test strip 10 parameter DUS (Silpa) 3 botol 240,000 720,000
16 Urine test strip 3 parameter (Silpa) 15 botol 83,000 1,245,000
17 Adult inhaler mask 100 biji 24,000 2,400,000
18 Child inhaler mask 100 biji 24,000 2,400,000
19 Kertas puyer lipat/ perkamen (Silpa) 35 pak 22,000 770,000
20 Plastik 1/4 kg (Silpa) 37 pak 13,000 481,000
21 Gelas Paper cup 6,5 oz (Silpa) 10 pak 25,000 250,000
22 Plastik obat Klip 10 x 7 (Silpa) 25 pak=1000 pcs 35,000 875,000
23 Plastik obat klip 8 x 12 (Silpa) 10 pak=1000 pcs 53,500 535,000

71,583,500
7,874,185
79,457,685

Jumlah Biaya
Sisa
G
Harga JUMLAH rba hps 1
Spesifikasi
Penawaran (Rp) ( Rp. )
29,970 599,400 Alkohol 70% kemasan botol 1L 30,525 30,000
111,000 111,000 Kemasan box 100's 111,000 111,000
160,950 160,950 9 jenis matriks berbahan metal 163,170 162,000
22,200 44,400 Dental microbus kemasan box 100's 22,200 22,200
17,760 88,800 Jarum jahit kulit GT 7 kemasan sachet 12's 17,760 17,760
17,760 88,800 Jarum jahit kulit GT 8 kemasan sachet 12's 17,760 17,760
17,760 88,800 Jarum jahit kulit GT 9 kemasan sachet 12's 17,760 17,760
17,205 86,025 Jarum jahit otot GR 7 kemasan sachet 12's 17,205 17,205
17,205 86,025 Jarum jahit otot GR 8 kemasan sachet 12's 17,205 17,205
17,205 86,025 Jarum jahit otot GR 9 kemasan sachet 12's 17,205 17,205
108,669 5,433,450 Stik asam urat, kemasan tube 25's 108,669 108,669
166,500 16,650,000 Stik kolesterol, kemasan tube 10's 167,888 167,000
93,795 4,689,750 Stik gula darah,kemasan tube 25s 94,017 93,900
493,950 40,503,900 Stik HB mission, kemasan box 50's 494,505 494,100
266,400 799,200 Strip urine 10 parameter Dus R, kemasan botol 100's 266,400 266,400
92,130 1,381,950 Strip urine 3 parameter Verify, kemasan botol 100's 92,463 92,400
26,640 2,664,000 Masker nebulizer set dewasa 26,640 26,640
26,640 2,664,000 Masker nebulizer set anak 26,640 26,640
24,420 854,700 Kertas puyer lipat, kemasan pak 500's 24,420 24,420
14,430 533,910 Kantong plastik bening ukuran 1/4kg 14,652 14,600
27,750 277,500 Gelas paper up 6,5 oz, kemasan pak 50's 27,750 27,750
38,850 971,250 Plastik klip obat ukuran 10x7cm, kemasan pak 1000's 39,072 39,000
59,385 593,850 Plastik klip obat ukuran 8x12cm, kemasan pak 1000's 59,385 59,385

79,457,685
hps 1 hps 2

600,000 30,100 602,000

111,000 111,000 111,000
162,000 163,000 163,000
44,400 22,300 44,600
88,800 17,800 89,000
88,800 17,800 89,000
88,800 17,800 89,000
86,025 17,300 86,500
86,025 17,300 86,500
86,025 17,300 86,500
5,433,450 109,000 5,450,000
16,700,000 166,500 16,650,000
4,695,000 93,800 4,690,000
40,516,200 494,500 40,549,000
799,200 266,500 799,500
1,386,000 92,200 1,383,000
2,664,000 26,700 2,670,000
2,664,000 26,700 2,670,000
854,700 24,600 861,000
540,200 15,500 573,500
277,500 27,750 277,500
975,000 39,000 975,000
593,850 59,500 595,000
79,540,975 79,590,600
83,290 132,915
 HARGA PERKIRAAN SENDIRI (HPS)
BELANJA BMHP 7
PADA UPT PUSKESMAS SUKODONO TA 2022

HARGA JUMLAH
No. Nama Barang VOLUME Spesifikasi
SATUAN (Rp) ( Rp. )
1 Alkohol 70% 1 L 20 Botol 30,000 600,000 Alkohol 70% kemasan botol 1L

2 Celluloid strip 1 box 111,000 111,000 Kemasan box 100's

3 Dental matrix spring clip 1 box 162,000 162,000 9 jenis matriks berbahan metal

4 Dental Microbrush 2 box 22,200 44,400 Dental microbus kemasan box 100's

5 Jarum Jahit kulit GT 7 5 set = 12 pcs 17,760 88,800 Jarum jahit kulit GT 7 kemasan sachet 12's

6 Jarum Jahit kulit GT 8 5 set = 12 pcs 17,760 88,800 Jarum jahit kulit GT 8 kemasan sachet 12's

7 Jarum Jahit kulit GT 9 5 set = 12 pcs 17,760 88,800 Jarum jahit kulit GT 9 kemasan sachet 12's

8 Jarum Jahit otot GR 7 5 set = 12 pcs 17,205 86,025 Jarum jahit otot GR 7 kemasan sachet 12's

9 Jarum Jahit otot GR 8 5 set = 12 pcs 17,205 86,025 Jarum jahit otot GR 8 kemasan sachet 12's

10 Jarum Jahit otot GR 9 5 set = 12 pcs 17,205 86,025 Jarum jahit otot GR 9 kemasan sachet 12's

11 Stik Asam Urat easytouch 50 botol 108,669 5,433,450 Stik asam urat, kemasan tube 25's

12 Stik Kolesterol easytouch 100 botol 167,000 16,700,000 Stik kolesterol, kemasan tube 10's

13 Stik gula darah easytouch 50 botol 93,900 4,695,000 Stik gula darah,kemasan tube 25s

14 Stik HB Mission 82 box 494,100 40,516,200 Stik HB mission, kemasan box 50's
Urine test strip 10 parameter Strip urine 10 parameter Dus R, kemasan botol
15 3 botol 266,400 799,200
DUS 100's
Strip urine 3 parameter Verify, kemasan botol
16 Urine test strip 3 parameter 15 botol 92,400 1,386,000
100's
17 Adult inhaler mask 100 biji 26,640 2,664,000 Masker nebulizer set dewasa
18 Child inhaler mask 100 biji 26,640 2,664,000 Masker nebulizer set anak
19 Kertas puyer lipat/ perkamen 35 pak 24,420 854,700 Kertas puyer lipat, kemasan pak 500's
20 Plastik 1/4 kg 37 pak 14,600 540,200 Kantong plastik bening ukuran 1/4kg
21 Gelas Paper cup 6,5 oz 10 pak 27,750 277,500 Gelas paper up 6,5 oz, kemasan pak 50's
Plastik klip obat ukuran 10x7cm, kemasan pak
22 Plastik obat Klip 10 x 7 25 pak=1000 pcs 39,000 975,000
1000's
Plastik klip obat ukuran 8x12cm, kemasan pak
23 Plastik obat klip 8 x 12 10 pak=1000 pcs 59,385 593,850
1000's
Total Harga 79,540,975

Mengetahui,
PPK

dr. RINA YULYA AGUSTIN

NIP. 19800814 201001 2 016
No. Nama Barang VOLUME Spesifikasi

1 Alkohol 70% 1 L 20 Botol Alkohol 70% kemasan botol 1L

2 Celluloid strip 1 box Kemasan box 100's

3 Dental matrix spring clip 1 box 9 jenis matriks berbahan metal

4 Dental Microbrush 2 box Dental microbus kemasan box 100's

5 Jarum Jahit kulit GT 7 5 set = 12 pcs Jarum jahit kulit GT 7 kemasan sachet 12's

6 Jarum Jahit kulit GT 8 5 set = 12 pcs Jarum jahit kulit GT 8 kemasan sachet 12's

7 Jarum Jahit kulit GT 9 5 set = 12 pcs Jarum jahit kulit GT 9 kemasan sachet 12's

8 Jarum Jahit otot GR 7 5 set = 12 pcs Jarum jahit otot GR 7 kemasan sachet 12's

9 Jarum Jahit otot GR 8 5 set = 12 pcs Jarum jahit otot GR 8 kemasan sachet 12's

10 Jarum Jahit otot GR 9 5 set = 12 pcs Jarum jahit otot GR 9 kemasan sachet 12's

11 Stik Asam Urat easytouch 50 botol Stik asam urat, kemasan tube 25's

12 Stik Kolesterol easytouch 100 botol Stik kolesterol, kemasan tube 10's

13 Stik gula darah easytouch 50 botol Stik gula darah,kemasan tube 25s

14 Stik HB Mission 82 box Stik HB mission, kemasan box 50's

Urine test strip 10 parameter
15 3 botol Strip urine 10 parameter Dus R, kemasan botol 100's
DUS
16 Urine test strip 3 parameter 15 botol Strip urine 3 parameter Verify, kemasan botol 100's

17 Adult inhaler mask 100 biji Masker nebulizer set dewasa

18 Child inhaler mask 100 biji Masker nebulizer set anak

19 Kertas puyer lipat/ perkamen 35 pak Kertas puyer lipat, kemasan pak 500's

20 Plastik 1/4 kg 37 pak Kantong plastik bening ukuran 1/4kg

21 Gelas Paper cup 6,5 oz 10 pak Gelas paper up 6,5 oz, kemasan pak 50's

22 Plastik obat Klip 10 x 7 25 pak=1000 pcs Plastik klip obat ukuran 10x7cm, kemasan pak 1000's

23 Plastik obat klip 8 x 12 10 pak=1000 pcs Plastik klip obat ukuran 8x12cm, kemasan pak 1000's

Total Harga 79,540,975

Tujuh puluh sembilan juta lima ratus empat puluh ribu sembilan ratus tujuh
Terbilang :
puluh lima Rupiah

Mengetahui,
PPK
 dr. RINA YULYA AGUSTIN
NIP. 19800814 201001 2 016
 Lampiran Berita Acara Hasil Pemeriksaan
Nomor : 602.1/ /427.52.20/PPK/2022
Tanggal : 25 November 2022

DAFTAR HASIL PEMERIKSAAN PEKERJAAN

Macam Barang yang Harga Satuan Jumlah Harga

No. Volume Keterangan
Diserahkan (Rp.) (Rp.)
1 Alkohol 70% 1 L 20 Botol 29,970 599,400 √
2 Celluloid strip 1 box 105,450 105,450 √
3 Dental matrix spring clip 1 box 158,730 158,730 √
4 Dental Microbrush 2 box 22,200 44,400 √
5 Jarum Jahit kulit GT 7 5 set = 12 pcs 17,760 88,800 √
6 Jarum Jahit kulit GT 8 5 set = 12 pcs 17,760 88,800 √
7 Jarum Jahit kulit GT 9 5 set = 12 pcs 17,760 88,800 √
8 Jarum Jahit otot GR 7 5 set = 12 pcs 17,205 86,025 √
9 Jarum Jahit otot GR 8 5 set = 12 pcs 17,205 86,025 √
10 Jarum Jahit otot GR 9 5 set = 12 pcs 17,205 86,025 √
11 Stik Asam Urat easytouch 50 botol 108,225 5,411,250 √
12 Stik Kolesterol easytouch 100 botol 167,610 16,761,000 √
13 Stik gula darah easytouch 50 botol 93,795 4,689,750 √
14 Stik HB Mission 82 box 493,950 40,503,900 √
Urine test strip 10 parameter
15 3 botol 266,400 799,200 √
DUS
16 Urine test strip 3 parameter 15 botol 92,130 1,381,950 √
17 Adult inhaler mask 100 biji 26,307 2,630,700 √
18 Child inhaler mask 100 biji 26,307 2,630,700 √
19 Kertas puyer lipat/ perkamen 35 pak 24,420 854,700 √
20 Plastik 1/4 kg 37 pak 14,430 533,910 √
21 Gelas Paper cup 6,5 oz 10 pak 26,640 266,400 √
22 Plastik obat Klip 10 x 7 25 pak=1000 pcs 38,850 971,250 √
23 Plastik obat klip 8 x 12 10 pak=1000 pcs 58,830 588,300 √

Total Harga 79,455,465

Keterangan :
√ : Baik
X : Kurang Baik
Penyedia Barang/Jasa PPK
PT. GRAHA SATYA PRATAMA

SUHARTO dr. RINA YULYA AGUSTIN

Direktur NIP. 19800814 201001 2 016
Lampiran Berita Acara Penerimaan Barang
Nomor : 602.1/ /427.52.20/PPK/2022
Tanggal : 25 November 2022

DAFTAR PENERIMAAN BARANG

Harga Satuan Jumlah Harga

No. Macam Barang yang Diperiksa Volume Keterangan
(Rp.) (Rp.)
1 Alkohol 70% 1 L 20 Botol 29,970 599,400 √
2 Celluloid strip 1 box 105,450 105,450 √
3 Dental matrix spring clip 1 box 158,730 158,730 √
4 Dental Microbrush 2 box 22,200 44,400 √
5 Jarum Jahit kulit GT 7 5 set = 12 pcs 17,760 88,800 √
6 Jarum Jahit kulit GT 8 5 set = 12 pcs 17,760 88,800 √
7 Jarum Jahit kulit GT 9 5 set = 12 pcs 17,760 88,800 √
8 Jarum Jahit otot GR 7 5 set = 12 pcs 17,205 86,025 √
9 Jarum Jahit otot GR 8 5 set = 12 pcs 17,205 86,025 √
10 Jarum Jahit otot GR 9 5 set = 12 pcs 17,205 86,025 √
11 Stik Asam Urat easytouch 50 botol 108,225 5,411,250 √
12 Stik Kolesterol easytouch 100 botol 167,610 16,761,000 √
13 Stik gula darah easytouch 50 botol 93,795 4,689,750 √
14 Stik HB Mission 82 box 493,950 40,503,900 √

15 Urine test strip 10 parameter DUS 3 botol 266,400 799,200 √

16 Urine test strip 3 parameter 15 botol 92,130 1,381,950 √

17 Adult inhaler mask 100 biji 26,307 2,630,700 √
18 Child inhaler mask 100 biji 26,307 2,630,700 √
19 Kertas puyer lipat/ perkamen 35 pak 24,420 854,700 √
20 Plastik 1/4 kg 37 pak 14,430 533,910 √
21 Gelas Paper cup 6,5 oz 10 pak 26,640 266,400 √
22 Plastik obat Klip 10 x 7 25 pak=1000 pcs 38,850 971,250 √
23 Plastik obat klip 8 x 12 10 pak=1000 pcs 58,830 588,300 √

Total Harga 79,455,465

Keterangan :
√ : Baik
X : Kurang Baik
 Yang Menyerahkan, Yang Menerima,
Kuasa Pengguna Anggaran Pejabat Pengurus Barang Pembantu

dr. RINA YULYA AGUSTIN YESSY GLADIANI SUTRISNO

NIP. 19800814 201001 2 016 NIP. 19950701 202012 2 011
 NOTA PENJUALAN
BELANJA BAHAN MEDIS HABIS PAKAI (BMHP) 7
PADA UPT PUSKESMAS SUKODONO TA 2022

Harga Satuan
No. Macam Barang yang Diperiksa Volume Jumlah Harga (Rp.)
(Rp.)
1 Alkohol 70% 1 L 20 Botol 29,970 599,400
2 Celluloid strip 1 box 105,450 105,450
3 Dental matrix spring clip 1 box 158,730 158,730
4 Dental Microbrush 2 box 22,200 44,400
5 Jarum Jahit kulit GT 7 5 set = 12 pcs 17,760 88,800
6 Jarum Jahit kulit GT 8 5 set = 12 pcs 17,760 88,800
7 Jarum Jahit kulit GT 9 5 set = 12 pcs 17,760 88,800
8 Jarum Jahit otot GR 7 5 set = 12 pcs 17,205 86,025
9 Jarum Jahit otot GR 8 5 set = 12 pcs 17,205 86,025
10 Jarum Jahit otot GR 9 5 set = 12 pcs 17,205 86,025
11 Stik Asam Urat easytouch 50 botol 108,225 5,411,250
12 Stik Kolesterol easytouch 100 botol 167,610 16,761,000
13 Stik gula darah easytouch 50 botol 93,795 4,689,750
14 Stik HB Mission 82 box 493,950 40,503,900

15 Urine test strip 10 parameter DUS 3 botol 266,400 799,200

16 Urine test strip 3 parameter 15 botol 92,130 1,381,950

17 Adult inhaler mask 100 biji 26,307 2,630,700
18 Child inhaler mask 100 biji 26,307 2,630,700
19 Kertas puyer lipat/ perkamen 35 pak 24,420 854,700
20 Plastik 1/4 kg 37 pak 14,430 533,910
21 Gelas Paper cup 6,5 oz 10 pak 26,640 266,400
22 Plastik obat Klip 10 x 7 25 pak=1000 pcs 38,850 971,250
23 Plastik obat klip 8 x 12 10 pak=1000 pcs 58,830 588,300
 Total Harga 79,455,465

Mengetahui Penyedia Barang/Jasa

PPK PT. GRAHA SATYA PRATAMA

dr. RINA YULYA AGUSTIN SUHARTO

NIP. 19800814 201001 2 016 Direktur