BERITA ACARA KEMAJUAN PEKERJAAN

TSSR PEROLEHAN KANDIDAT SITE

Pekerjaan : EPC/ AL&PM PEMBANGUNAN MENARA BERSAMA TELEKOMUNIKASI (XL)

Lokasi/ Site ID : BANJAR_TENGAH_NEGARA / R5100253
Type Tower/ Tinggi : Monopole / 32 M
Nomor BAKP : /CMI-DEV/BAKP-TSSR/SITAC/ /2022

Pada hari ini tanggal bulan tahun yang bertandatangan di

bawah ini telah melaksanakan pekerjaan, dengan rincian sebagai berikut:

Volume Pekerjaan /material Progress

No UraianPekerjaan Catatan
Kontrak/PO Realisasi Hasil Fisik
1 EPC-SITAC : SAR 1 1 Ok 100 %

Berdasarkan:

1. Kontrak nomor : 080/AMD.1-EPC/CMI-SI/XI/2021

2. PO nomor : CMIPO22001465
3. Berita Acara Pemeriksaan : /CMI-DEV/BAPKP-TSSR/SITAC/ /2022
Kemajuan Pekerjaan nomor

Pekerjaan tersebut di atas dinyatakan telah dicapai progress kemajuan pekerjaan TSSR yang telah
disetujui pada tanggal bulan tahun sesuai dengan Berita Acara Pemeriksaan
Kemajuan Pekerjaan TSSR Perolehan Kandidat Site (BAPKP-TSSR Perolehan Kandidat Site) .

Demikian Berita Acara ini dibuat dengan sebenarnya untuk dapat dipergunakan sebagaimana
mestinya.

Diterima Oleh Diserahkan Oleh

PT. CENTRATAMA MENARA INDONESIA PT. SAMKANG INDONESIA

Rike Novisia Kasayu Tri Wibowo

Tower Imp. Dept. Head Direktur Utama
 BERITA ACARA PEMERIKSAAN KEMAJUAN PEKERJAAN
TSSR PEROLEHAN KANDIDAT SITE

Pekerjaan : EPC/ AL&PM PEMBANGUNAN MENARA BERSAMA TELEKOMUNIKASI (XL)

Lokasi/ Site ID : BANJAR_TENGAH_NEGARA / R5100253
Type Tower/ Tinggi : Monopole / 32 M
Nomor BAPKP : /CMI-DEV/BAPKP-TSSR/SITAC/ /2022

Pada hari ini tanggal bulan tahun yang bertandatangan

di bawah ini:

No. NAMA INSTANSI

1 Kitson Hutabarat PT. CMI Project Manager

2 Bayu Prasetyo PT. Samkang Indonesia PIC Lapangan

Berdasarkan:
1. Kontrak nomor : 080/AMD.1-EPC/CMI-SI/XI/2021
2. PO nomor : CMIPO22001465
3. Tanggal Pemeriksaan :

Secara bersama – sama telah melakukan pemeriksaan terhadap TSSR Perolehan Kandidate Site dengan
hasil sebagai berikut :

√ TSSR Perolehan Kandidat Site telah disetujui Oleh Centratama Menara Indonesia

TSSR Perolehan Kandidat Site telah disetujui Oleh Centratama Menara Indonesia dengan
catatan
( Harus melampirkan MoM/Kronologis/Justifikasi)

TSSR Perolehan Kaandidat Site tidak disetujui Oleh Centratama Menara Indonesia dan harus
dilakukan pencarian kandidat site ulang
( Selambat-lambatnya _____hari kerja terhitung sejak tanggal Berita Acara ini )

TSSR Perolehan Site terlampir.

Berita Acara ini rangkap 2 (dua) asli, untuk kepentingan kedua belah pihak dalam rangka penerbitan Berita
Acara Kemajuan Pekerjaan TSSR PEROLEHAN KANDIDAT SITE (BAKP-TSSR PEROLEHAN KANDIDAT SITE).
Diperiksa dan disetujui :

PT. CENTRATAMA MENARA INDONESIA PT. Samkang Indonesia

Disetujui Paraf TTD
Project Manager PIC Lap. Project Manager

( Kitson Hutabarat ) ( Bayu Prasetyo ) ( Beja Waluya )

 LAMPIRAN
PO MILESTONE PROSENTASE LAMPIRAN REMARKS

PEKERJAAN SITAC
SAR
Termin-1 T-0 40% PO, BAKP&BAPKP DRM Nominal delivered form CMI to Contractors
Termin-2 TSSR Done 60% PO, BAKP&BAPKP TSSR Site Validasi by Operator & CMI
SITAC - Services
Termin-1 BAK 40% PO, BAKP&BAPKP BAK BAK Approved by LO, Kontraktor, CMI
Termin-2 BAST 60% PO, BAKP&BAPKP BAST-Sitac Sitac Binder Approval CMI
IMB
Termin-1 Resi/Rekom Zona 20% PO, BAKP&BAPKP Resi/Rekom Zona (yg issued duluan) BAK Approved by LO, Kontraktor, CMI
Termin-2 BAST 80% PO, BAST-IMB IMB Issue
PEKERJAAN CME
CME - General Scope & Service
Termin-1 APD 30% PO, BAKP&BAPKP APD APD Approved by RA & Operator
Termin-2 BAST 1 60% PO, BAKP&BAPKP BAST 1 ATP Done & Binder CME Done
Termin-3 BAST 2 10% PO, BAKP&BAPKP BAST 2 BAST 1, Approval No-Pending Item CME & Sitac
TOWER
Termin-1 BAK 65% PO, BAKP&BAPKP BAK-TOWER BAK Approved by LO, Kontraktor, CMI
Termin-2 MOS 35% PO, BAKP&BAPKP MOS Tower Erected until 2 section
PLN
Termin-1 BAST PLN 100% PO, BAKP&BAPKP BAST PLN PLN Connected
PEKERJAAN KOLOKASI
Termin-1 BAST 1 90% PO, BAKP&BAPKP BAST 1 ATP Done & Binder CME Done
Termin-2 BAST 2 10% PO, BAKP&BAPKP BAST 2 BAST 1, Approval No-Pending Item CME & Sitac
 TECHNICAL SITE SURVEY REPORT (TSSR)
Checklist / Table of Contents
CENT Site ID R5100253 TSS Date: 01-Dec-22
Customer Site ID BAL-BA-NGA-1493 Contractor: PT. SAMKANG INDONESIA
Candidate J CENT Supervisor: AGUS PRIYONO
Hard Copy Soft Copy
Items Original (X) Remarks
(X) (X)

1 Table of Contents and Routing Approval <soft copy Required in excel>

TSSR
2 <soft copy Required in excel>
(Cust TSS, CENT TSS, Sketches, Panoramic, Power-Access)

8
Contractor Name Name (PM of Contractor) Signature and Date

Prepared by:
PT. SAMKANG INDONESIA BEJA WALUYA

CENT Representative Name and Position Signature and Date

Reviewed by: AGUS PRIYONO

PT. CENTRATAMA MENARA INDONESIA

(a) Encircle Status

Approver Risk Assessments/ Flood/ Overall Remarks (b) Signature and Date
Note : A. Approved and PREFERED Candidate
confirm coordinate & Tower Height as validated by B. Approved as back up Candidate
Planning C. Disapproved
CENT SITAC Manager

Note : A. Approved and PREFERED Candidate

Approved Cand. J B. Approved as back up Candidate
Site condition normal, Access normal, need small bridge C. Disapproved
CENT Project Manager 0.3 x 3 m, Tower type monopole 32 m, PLN Votage 221 V
Andhika Juwandra (Normal),
PLN Part, Normal Voltage With 100 Meters Cable & 2 A. Approved and PREFERED Candidate

A. Approved and PREFERED Candidate

B. Approved as back up Candidate
CENT Senior Project C. Disapproved
Manager

DIN-00028-TP01 TSSR

DIN-PS00-SD0001-TP01 TSSR TOC1

 Technical Site Survey Report
R5100253 BAL-BA-NGA-1493 J
Customer Site Name BANJAR TENGAH NEGARA Customer Site ID BAL-BA-NGA-1493Candidate Letter : J

PART 1: GENERAL INFORMATION

1 Reference
CENT Site ID R5100253 Project B2S XL Date of Survey 1-Dec-22
Customer Site ID BAL-BA-NGA-1493 Search Ring Radius 150 M TSSR Version: 001
Candidate Letter J Actual Radius 121 M Prepare By: CATUR P
Latitude 8°21'40.71"S Nom. Latitude 8°21'39.71"S Contractor: PT. SAMKANG INDONESIA
Longitude 114°37'3.64"E Nom. Longitude 114°36'59.98"E
Proposed Tower Ht. (m) MP 32 M Planned Tower Ht. (m) MP 32 M GBT/Rooftop GBT
Please use the word "GBT"or "Rooftop"

2 Contact Reference
Site Address Jalan Arjuna, Kelurahan Lelateng

Kecamatan/Kelurahan Negara Kabupaten Jembrana Province Bali

LL name Erik Putra Sanjaya LL Contact 081999330045

LL Representative Name Representative Contact

3 Survey Participants
Function Name Company Contact Information
CME Contractor: Catur Prayitno PT. Samkang Indonesia 081233994981
SITAC Contractor: Kadek Satya PT. Samkang Indonesia +62 812-4607-1594
Radio Planning:

Transmission:

LL / Representative: Erik Putra Sanjaya Owner 081999330045

CENT SITAC
Representative:
CENT CME
Representative: Agus Priyono PT. CMI 08553000080

4 Categorization
Site Type Building Type Owner Type
Rooftop Office Building Govt

GBT GBT Residential Building Private √

Private House Corporate
Religious Institution
Shopping Complex City/Town/Local
Others vacant yard

5 Risk Assesment
Risks Items Yes/ No Risk Remarks/ Notes
Flood Prone Area No
Highest Flooding level (m) No
Near Rivers, Lakes, water bed, Creek No
High Voltage area (Power) No
Distance to nearest transformer Yes + 340m
Voltage of residentials nearby Yes + 5m
Landslide prone area, near to cliff No
Near to trees Yes Banana Trees
Near to Airport No
Chemical hazard area, Fire safety of the area No
Insurgency/ Rebels (local) No
Structural failure No
Access is difficult during Rainy Season No
Access is difficult the whole year No
Material Transport is high Yes
Wild animals roaming around No
Labor/Workers Availability Yes
Construction Materials Availability Yes
Other Risk No

DIN-00028-TP01 TSSR CENT TSS 1 of 4

 Technical Site Survey Report
R5100253 BAL-BA-NGA-1493 J
Customer Site Name BANJAR TENGAH NEGARA Customer Site ID BAL-BA-NGA-1493Candidate Letter : J

PART 2: ACCESIBILITY INFORMATION

6 CME Material Transport and Accessibility

6.1 From Main Road to Village/Village Road

Distance (m) and Accessible during Rainy Requirements/ Obstructions/
Yes/No Improvement Needed (Yes/No)
Hours of Travel (hrs) Season (Yes/No) Comments

Walk/Manual Yes 517m / 25 minutes No Yes

Motorcycle Yes 517m / 5 minutes No Yes
Small Truck Yes 517m / 5 minutes No Yes
Large Truck (10
No - No -
wheeler and up)
4 x 4 Vehicle No - No -
Boat No - No -
Animals No - No -
Others No - No -

6.2 From Village/ Village Road to Site

Distance (m) and Accessible during Rainy Requirements/ Obstructions/
Yes/No Improvement Needed (Yes/No)
Hours of Travel (hrs) Season (Yes/No) Comments
Walk/Manual Yes 35m / 2 minutes No Yes
35m / Less than 1
Motorcycle Yes No Yes
minute
35m / Less than 1
Small Truck Yes No Yes
minute
Large Truck (10
No - No -
wheeler and up)
4 x 4 Vehicle No - No -
Boat No - No -
Animals No - No -
Others No - No -

7 Rooftop: Site Accessibility

Description Special Instructions
Accesibile Hours
Accesibile Days
Keys Location
Keys Contact
Prior Notice required
Special Access Procedure/ House Rules /Access and Noise Production Restrictions

8 Rooftop: Facilities for Accessibility

Elevator Dim W/D/H Elevator Door Dim W/H
Elevator available
(cm) (cm)
Elevator Load Capacity
[kg]
Access via Internal Number of Floors or
Width of Staircase [cm]
Staircase/ Capacity Flights
Access via External Number of Floors or
Width of Staircase [cm]
Staircase/ Capacity Flights
Access via Internal Ladder Rooftop Floor Area (m x
Ladder Height [m]
/ Capacity m)
Access via External Safety System available
Ladder / Capacity (e.g. Back Cage)
Rooftop Access via Door Door Width / Height [cm]
Rooftop Access via Trap Hatch Width / Length
Door / Hatch [cm]
Work Area Light
Access Light Sufficient
Sufficient

DIN-00028-TP01 TSSR CENT TSS 2 of 4

 Technical Site Survey Report
R5100253 BAL-BA-NGA-1493 J
Customer Site Name BANJAR TENGAH NEGARA Customer Site ID BAL-BA-NGA-1493Candidate Letter : J

PART 3: CIVIL, MECHANICAL AND ELECTRICAL INFORMATION

9 Civil and Structural Details

9.1 Greenfield General Details
Planned Tower Ht. (m) 32 m Proposed Tower Ht. (m) 32 m Planned Tower height is the required tower height by customer.

Ground Elevation AMSL

(m)
17m Proposed Tower Type 32-MP Tower Type: 42-3L, 62-4L, 30-MP

Lease Area (m)
Highest Flooding level (m)
2
8 x 7 = 56 M Fence Area (m) 8x7m Iindicate the Length X Width in meters
Landlord Lot Total Open
- area (m)
- Iindicate the Length X Width in meters

3m Site Access
Specify the length in
(to Improved/ to Construct / Noneed meters if less than 3m
(L) 1m x (W) 3m Site development includes 3m site access improvement/construction
Existing)

General Soil Type Soil General Type Site Improvement Requirement

Flat √ Normal Clearing √
Slope Rocky Stripping
Hilly Sandy Cut/Fill √
Swamp Clay √ Demolish
Build New Small Bridge for
Others Others
access to site
Obstruction in lease area Obstruction On Solar Panels Possible Generator Set Disturbance
None None √ Neighbor/ LL √
Trees √ Trees Schools
House House Temple/Church
Others Others Others

9.2 Rooftop General Details

Building Height (m) Approx. Building Age Plans Available

Building Height AMSL (m) Number of Floors/ Stories Current Building Use

Yes/No Remarks Yes/No Remarks

Requires to puncture roof or
With Renovation Requires to open walls or
panelling
Water Tanks or ACU in
Nearby Power availability
roof top
Signage or Billboards in
Penthouse/ Obstacles
rooftop

Good/Moderate/Poor Materials Used Other comments

Overall Structural
Condition
Columns and Beams
Building Walls/Tower
Frame
Ceilings

Floor Slab

Roof

Parapet/Railings

Waterproofing

10 Grounding and Lightning Protection System

Existing LPS Condition of LPS
No. of Existing down
Connection of LPS
Conductors

11 New Power Supply and Electrical Data

Required to use local
Grid Power Available
(Yes/No)
Yes supplier for installation Yes
(Yes/No)
Existing Power Supply Power Supply Company Distance from existing
Capacity
1 x 100KVA Contact Person
- transformer (m)
340 m
Distance from existing
Power Supply Company PLN Poles (m)
40 m Electrical Pole Needed 1 pole
Site Located in Urban /
Unit Price/kw - Location of Power Meter 5m Residential Area
Urban
Local Meter availability Power supplier Govt Need Generator Room
(weeks)
- /Private
Govt (Yes/No)
No
Solar Power Possible Solar Space / Area Solar South Orientation
(Yes/No)
NO Available (Yes/No)
- Possible (Yes/No)
No

DIN-00028-TP01 TSSR CENT TSS 3 of 4

 Technical Site Survey Report
R5100253 BAL-BA-NGA-1493 J
Customer Site Name BANJAR TENGAH NEGARA Customer Site ID BAL-BA-NGA-1493Candidate Letter : J

12 Setbacks and Clearance

Items Yes/ No Distance (m) Risk Remarks/ Notes
School Yes 290m SMA Ngurah Rai Negara
Church/ Place of Worship Yes 425m Catholic Church Santo Petrus
Hospital Yes 850m RSU Negara
Lakes No
Rivers No
Main Road Yes 552m Jalan Nasional Gilamanuk-Denpasar
Village Road Yes 35m
Govt Offices Yes 1 km
Village Hall/ Offices Yes 790m Kantor Kelurahan Lelateng
Airport Runway No

PART 4: ADDITIONAL SITE IMPROVEMENTS

13 Access Improvements
Improvement Type
Items Distance (m) Improvement Details (Provide Sketch and Photos)
(Upgrade/ New)
Access Improvement
from Main Road to
Village
Access Improvement
from Village to Site 1 ( Meter ) New Build New Small Bridge for access to site

14 Site Components Improvements

Items Yes/No Details

Demolish Structure No
Site Leveling No
Piling Works - Depend on Soil Test report

Retaining Wall No
Aircraft Warning Lights Yes
Perimeter Drainage No
Cabin Drainage No
Beams/Columns for Reinforcement No
Vertical/ Horizontal Cable Ladder for Rooftops No
Handrail for rooftop No
Others Yes New Small bridge for access to site (1 x 3m)

DIN-00028-TP01 TSSR CENT TSS 4 of 4

 Site Location Sketch
Sketch all of the following including dimensions and compass orientation
1 Lease area location

2 Surrounded structures and distance from the site

3 Location of existing power line, pole and power entrance to site

CENT Site ID: R5100253

Customer Site ID: BAL-BA-NGA-1493 Candidate J

DIN-00028-TP01 TSSR Sketches 1 of 2

 Site Layout Sketch
Sketch all of the following including dimensions and compass orientation
Top view of building structure with column and beam
1 Greenfield site- Filling the table or in sketch attached 4 dimensions.
Top view of building with proposed tower and equipment
2 Vicinity in lease area and surrounding 5 slab locations.
Other information for building analysis (Beam column its
3 Building roof with existing items on top and dimensions. 6 rebar…)

CENT Site ID: R5100253

Customer Site ID: BAL-BA-NGA-1493 Candidate J

DIN-00028-TP01 TSSR Sketches 2 of 2

 Technical Site Survey Report
R5100253 BAL-BA-NGA-1493 J
CENT Site ID Customer Site ID Candidate Letter

Photos: Site

Site Location 15.1 GPS Photo : 8°21'40.71"S, 114°37'3.64"E

Latitude (Decimal) -8,361308°
Description/Remarks : Length : 8 m Description/Remarks : Width : 7 m
Longitude (DMS) 114,617678°

Front Back

Remarks Remarks

Left Right

Remarks Remarks

DIN-00028-TP01 TSSR Site Photos 1 of 3

 Technical Site Survey Report
R5100253 BAL-BA-NGA-1493 J
CENT Site ID Customer Site ID Candidate Letter

Photos: Site

Surrounding area in 200m radius Surrounding area in 500m radius

Description/Remarks Description/Remarks

Land Mark 1 in 200m radius Land Mark 1 in 500m radius

Description/Remarks : Balai Banjar Description/Remarks : Hotel & Pertokoan

Proposed Location Photo 1 Proposed Location Photo 2

Remarks : front view Remarks : back view

DIN-00028-TP01 TSSR Site Photos 2 of 3

 Technical Site Survey Report
R5100253 BAL-BA-NGA-1493 J
CENT Site ID Customer Site ID Candidate Letter

Photos: Site

Lease Area -0,10m from 0,00 Level Village Road Village Road : Width 2,30m (Aspalt)

Remarks Remarks

Nominal Point is Existing Tower 3Legs 32m 1 Tenant Installed : H3I

Remarks Remarks

Clearing : Banana Trees Build New Small Bridge in front of Lease area

Remarks Remarks : drainnage => width 0.30m, depth 0.50m

DIN-00028-TP01 TSSR Site Photos 3 of 3

 Technical Site Survey Report
DIN-PS00-SD0001-TP01 TSSR R5100253 BAL-BA-NGA-1493 J
CENT Site ID Customer Site ID Candidate Letter

Panoramic Photos

0⁰ 30⁰

Remarks Remarks

60⁰ 90⁰

Remarks Remarks

120⁰ 150⁰

Remarks Remarks

DIN-00028-TP01 TSSR Panoramic 1 of 2

 Technical Site Survey Report
DIN-PS00-SD0001-TP01 TSSR R5100253 BAL-BA-NGA-1493 J
CENT Site ID Customer Site ID Candidate Letter

Panoramic Photos

180⁰ 210⁰

Remarks Remarks

240⁰ 270⁰

Remarks Remarks

300⁰ 330⁰

Remarks Remarks

DIN-00028-TP01 TSSR Panoramic 2 of 2

 Technical Site Survey Report
R5100253 BAL-BA-NGA-1493 J
CENT Site ID Customer Site ID Candidate Letter

Power

Transformer : Capacity 100KVA Transformer : Capacity 100KVA

Coming Up Transformer Location - 340m away from site Nearest Pole - Noneed New pole - 13m away from site

Nearest Pole Existing (JTR) Proposed 1 new pole

Nearest Pole : 40m away from Site Need 1 new pole - 35 m from site

Voltage of residentials nearby Voltage of residentials nearby

Distance : 5m away from site Voltage Measurement : 221 VA

DIN-00028-TP01 TSSR Power -Access 1 of 3

 Technical Site Survey Report
R5100253 BAL-BA-NGA-1493 J
CENT Site ID Customer Site ID Candidate Letter

Access

PORTAL
PORTAL
Access from Main Road (552m to site) Arjuna Road (517m)

Remarks : Jalan Nasional Gilimanuk-Denpasar Remarks : width 5m, but there are 2 Portals in left n' right side of road

n/a n/a

Arjuna Road, Turn right to Village Road (Gang Buntu) 35m to site Village Road (Gang Buntu) 35m to site

Remarks Remarks

n/a n/a

Village Road (Gang Buntu) 35m to site SITE

Remarks : drainnage in left and rigth side of villlage road Remarks :

DIN-00028-TP01 TSSR Power -Access 2 of 3

 Technical Site Survey Report
R5100253 BAL-BA-NGA-1493 J
CENT Site ID Customer Site ID Candidate Letter

191

30 45

Distance from main road to Site : 552m

DIN-00028-TP01 TSSR Power -Access 3 of 3