Medan, 15 Oktober 2022

Kepada Yth.
Nomor Aju PPK : E/A/E/46.0/X/2022/000219 Kepala Stasiun KIPM Medan II
Lampiran : Di
Perihal : Surat Permohonan Penerbitan HC Medan

Dengan ini kami mengajukan permohonan penerbitan Health Certificate (HC) dengan rincian data sebagai berikut :
1 Comodity Name
: FROZEN CUTTLE FISH
2 Scientific Name
: Sepiida spp.
3 Number Of Packages : 1,803 CARTONS
4 Net Weight : 17,128.50 KGS
5 Production Place : BELAWAN, INDONESIA
6 Processing Type : FROZEN
7 Production Mode : ***
8 Aquacultured : Yes / No
Wild Caught : Yes / No
9 Aquaculture area
10 Catch Area : WPP – RI 571
Name & Number Vessel for the : KELELAWAR 88 V/46.0.00080 INDONESIA
catch
11 Production and processing : PT. LAUTAN PERSADA
enterprise name and registration
number : CR 631 – 02
12 Production Date : OCTOBER 13, 2022
13 Name and address of consignor : PT. LAUTAN PERSADA
JL. GABION PERIKANAN PERUM. PRASARANA PERIKANAN
SAMUDERA BELAWAN KEL. BAGAN DELI, KEC. MEDAN
BELAWAN, SUMATERA UTARA, 20414 INDONESIA

14 Name and address of consignor : QINGDAO CAISHI IMP & EXP CO.,LTD
ADD: ROOM 202, 5 UNIT NO. 92 LUSHAN ROAD
ECONOMIC & TECHNOLOGICAL DEV ZONE OF
QINGDAO, CHINA 266555

15 Place of dispatch : BELAWAN, INDONESIA

16 Place of Destination : QINGDAO, CHINA
17 Means of Transport : VESSEL
18 Name of Vessel : MERATUS MEDAN 5 V.242N
19 Flight Number : ***
20 Other Transport Means : ***
21 Container Number : SUDU8235464
22 Seal Number : ML-ID0217078
23 Date of Delivery : OCTOBER 19, 2022

Stasiun KIPM Medan II Cap dan Tanda Tangan Perusahaan

Diterima Oleh :
Tanggal :
No. Agenda :
Cap dan Tanda Tangan

Form 01 Pelayanan Penerbitan Health Certificate Stasiun KIPM Medan II B

CHINA
 PPK EKSPOR
NOMOR PENGAJUAN : E/A/E/46.0/X/2022/000219
STATUS : TERKIRIM

Data Pengajuan Data Pelabuhan

Jenis Komoditi : Ikan Non-Hidup Pelabuhan Muat : IDBLW - BELAWAN
Maksud Kegiatan : Diperdagangkan Pelabuhan Transit : -
Peruntukan : Konsumsi Pelabuhan Bongkar : CNTAO - Qingdao
UPT : Stasiun Karantina Ikan, Pengendalian Mutu Tempat Penimbunan :
dan Keamanan Hasil Perikanan Medan II
KPBC : 010700 - KANTOR PELAYANAN BELAWAN
Data Sarana Angkut Transit
Cara Angkut :
Pemilik Barang Nama Angkut :
NPWP : 03.060.590.1-112.000
Nomor Voy/Flight :
Nama : PT LAUTAN PERSADA
Bendera :
JL. GABION PERIKANAN PERUM PRASARANA
PERIKANAN SAMUDERA BELAWAN, KEL.
Alamat : BAGAN DELI, KEC. MEDAN BELAWAN, Data Sarana Angkut Akhir
SUMATERA UTARA,
20414 INDONESIA Cara Angkut : Laut

Kode Pos : 20414 Nama Angkut : MERATUS MEDAN 5

Nomor Voy/Flight : 242N
Bendera : Indonesia
Data Penerima
Nama : QINGDAO CAISHI IMP & EXP CO.,LTD
ADD: ROOM 202, 5 UNIT NO. 92 LUSHAN Informasi Lain
ROAD ECONOMIC & TECHNOLOGICAL DEV Negara Tujuan : China
Alamat : ZONE OF QINGDAO, CHINA 266555 TEL: 86
532 Nilai : 453905250
86999391, 0532-86997038 Bruto : 18570.90 Kilogram (KGM)
Negara Asal : China Netto : 17128.5 Kilogram (KGM)

Data PPJK/EMKL Data Penandatangan Dokumen PPK

NPWP : Nama TTD : Alfin Silitonga
Nama : Jabatan TTD : Quality Control
Alamat : JL. GABION PERIKANAN PERUM
Kode Pos : PRASARANA PERIKANAN SAMUDERA
Tempat TTD :
BELAWAN, KEL. BAGAN DELI, KEC.
MEDAN BELAWAN
Data Penanggungjawab Tanggal TTD : 13-10-2022
Nama : ALFIN SILITONGA
JL. JUANDA III LK. VKEL. MENCIRIM KEC.
Alamat :
BINJAI TIMUR KOTA BINJAI
Nomor Telepon : 082310137468

Data Pemeriksa
JL. GABION PERIKANAN PERUM PRASARANA
Lokasi Periksa :
PERIKANAN SAMUDERA BELAWAN, KEL.
JL. GABION PERIKANAN PERUM PRASARANA
Alamat Periksa :
PERIKANAN SAMUDERA BELAWAN, KEL.
Tanggal Periksa : 14-10-2022
Tanggal Kirim : 19-10-2022

PPK Ekspor - E/A/E/46.0/X/2022/000219 | Hal. 1 Dari 3

 PPK EKSPOR
NOMOR PENGAJUAN : E/A/E/46.0/X/2022/000219

DETAIL BARANG

Kode HS Uraian Barang Nama Latin Jumlah Satuan Nilai (Rp) Keterangan

03074390  Frozen Cuttle Fish  Sepiida spp 17.128,50 KILOGRAM 453.905.250

TOTAL  0 HDS   0 PCE   17.128,5 KGM   0 GRAM   0 LTR   0 MLT 

DETAIL KEMASAN

Jenis Kemasan Merk Jumlah Bahan

Carton 1.803 LAINNYA

DETAIL DOKUMEN

Nama Dokumen No. Dokumen Tgl. Dokumen Negara

Invoice 017/LP/E/X/2022 13-10-2022 Indonesia

Hazard Analysis Critical Control Point (HACCP) 163/PM/HACCP/PB/06/21 25-06-2021 Indonesia

DETIL KONTAINER

No. Kontainer Ukuran Jenis Stuff Tipe No. Segel

SUDU8235464 40 Feet FCL Reefer/Refrigerate ML-ID0217078

PPK Ekspor - E/A/E/46.0/X/2022/000219 | Hal. 2 Dari 3

 PPK EKSPOR
NOMOR PENGAJUAN : E/A/E/46.0/X/2022/000219

DETAIL MUTU

No. REG / License CR 631-02

Nama UPI PT. LAUTAN PERSADA

JL. GABION PERIKANAN PERUM. PRASARANA PERIKANAN SAMUDERA BELAWAN. KEL. BAGAN
Alamat UPI DELI, KEC. MEDAN BELAWAN, SUMATERA UTARA,
20414 - INDONESIA
Telp. UPI 061-6943049

No. Registrasi UE UPI

Negara UPI China

Negara Asal Produk Indonesia

Deskripsi Produk FROZEN CUTTLE FISH

Kode / Tgl. Produksi OCTOBER Tanggal Produksi : 13-10-2022

No / Tgl. Surveilance 095/46.0/SKV/08/22 Tanggal Surveilance : 16-08-2022

Jenis cumi-cumi dan
Kode HS 03074390 Uraian HS :
sotong lainnya; Beku
Aqua Cultured / Area Cultured - Kota/Kabupaten : -

Wild Cought / Area Tangkap WPP-RI 571 - Selat Malaka dan Laut Andaman

Jenis Produk Fishery Product

Nama Kapal Pengolah / Tangkap KELELAWAR 88 V/46.0.00080 INDONESIA

Gudang Cold Storage PT. LAUTAN PERSADA

Temperatur -21 Jenis Temperatur : Frozen / Beku

Processing Type FROZEN

PPK Ekspor - E/A/E/46.0/X/2022/000219 | Hal. 3 Dari 3

 INVOICE
NO. 017/LP/E/X/2022

DATED : OCTOBER 13, 2022

SHIPPER : PT. LAUTAN PERSADA

JL. GABION PERIKANAN PERUM. PRASARANA PERIKANAN
SAMUDERA BELAWAN KEL. BAGAN DELI, KEC. MEDAN BELAWAN,
SUMATERA UTARA, 20414 INDONESIA
CONSIGNEE : QINGDAO CAISHI IMP & EXP CO.,LTD
ADD: ROOM 202, 5 UNIT NO. 92 LUSHAN ROAD
ECONOMIC & TECHNOLOGICAL DEV ZONE OF
QINGDAO, CHINA 266555
TEL: 86 532 86999391, 0532-86997038
NOTIFY : SAME AS CONSIGNEE
VESSEL : MERATUS MEDAN 5 V.242N
DESTINATION : QINGDAO, CHINA
PORT OF LOADING : BELAWAN, INDONESIA
SHIPPING ON : OCTOBER 19, 2022
CONT. AND SEAL NO. : SUDU8235464 / ML-ID0217078 / 40"RQ
PAYMENT METHODE : 100% T/T IN ADVANCE

QUANTITY NET WEIGHT PRICE CFR AMOUNT CFR

DESCRIPTION OF GOODS SIZE
CARTONS KGS (USD/KG) (USD)

1. FROZEN CUTTLE FISH

----------------------------------------------- 20G - 50G 123 1,168.50 1.80 2,103.30
----------------------------------------------- 50G - 100G 321 3,049.50 2.80 8,538.60

FROZEN CUTTLE FISH (GRADE A)

----------------------------------------------- 100G - 200G 149 1,415.50 3.00 4,246.50
----------------------------------------------- 200G - 300G 170 1,615.00 3.40 5,491.00
----------------------------------------------- 300G - 500G 189 1,795.50 3.80 6,822.90
----------------------------------------------- 500G - 700G 230 2,185.00 3.80 8,303.00
----------------------------------------------- 700G - 1000G 157 1,491.50 3.80 5,667.70
----------------------------------------------- 1000G - 1500G 36 342.00 3.80 1,299.60

FROZEN CUTTLE FISH (GRADE AA)

----------------------------------------------- 100G - 200G 39 370.50 3.10 1,148.55
----------------------------------------------- 200G - 300G 33 313.50 3.50 1,097.25
----------------------------------------------- 300G - 500G 54 513.00 3.90 2,000.70
----------------------------------------------- 500G - 700G 131 1,244.50 3.90 4,853.55
----------------------------------------------- 700G - 1000G 127 1,206.50 3.90 4,705.35
----------------------------------------------- 1000G - 1500G 44 418.00 3.90 1,630.20

SUB TOTAL - 1 1,803 17,128.50 57,908.20

2. FROZEN SQUID
----------------------------------------------- 8-10 (200G-300G) 363 3,448.50 3.00 10,345.50
----------------------------------------------- 10-12 (300G-500G) 197 1,871.50 3.20 5,988.80
----------------------------------------------- 12-14 (500G-700G) 165 1,567.50 3.50 5,486.25
----------------------------------------------- 14 UP (700G UP) 72 684.00 3.50 2,394.00

SUB TOTAL - 2 797 7,571.50 24,214.55

TOTAL CFR QINGDAO, CHINA 2,600 24,700.00 82,122.75

Yours Faithfully,
PT. LAUTAN PERSADA
 PACKING LIST
NO. 017/LP/E/X/2022

DATED : OCTOBER 13, 2022

SHIPPER : PT. LAUTAN PERSADA

JL. GABION PERIKANAN PERUM. PRASARANA PERIKANAN
SAMUDERA BELAWAN KEL. BAGAN DELI, KEC. MEDAN BELAWAN,
SUMATERA UTARA, 20414 INDONESIA
CONSIGNEE : QINGDAO CAISHI IMP & EXP CO.,LTD
ADD: ROOM 202, 5 UNIT NO. 92 LUSHAN ROAD
ECONOMIC & TECHNOLOGICAL DEV ZONE OF
QINGDAO, CHINA 266555
TEL: 86 532 86999391, 0532-86997038
NOTIFY : SAME AS CONSIGNEE
VESSEL : MERATUS MEDAN 5 V.242N
DESTINATION : QINGDAO, CHINA
PORT OF LOADING : BELAWAN, INDONESIA
SHIPPING ON : OCTOBER 19, 2022

CONT. AND SEAL NO. : SUDU8235464 / ML-ID0217078 / 40"RQ

QUANTITY NET WEIGHT GROSS WEIGHT

DESCRIPTION OF GOODS SIZE
CARTONS KGS KGS

1. FROZEN CUTTLE FISH

----------------------------------------------- 20G - 50G 123 1,168.50 1,266.90
----------------------------------------------- 50G - 100G 321 3,049.50 3,306.30

FROZEN CUTTLE FISH (GRADE A)

----------------------------------------------- 100G - 200G 149 1,415.50 1,534.70
----------------------------------------------- 200G - 300G 170 1,615.00 1,751.00
----------------------------------------------- 300G - 500G 189 1,795.50 1,946.70
----------------------------------------------- 500G - 700G 230 2,185.00 2,369.00
----------------------------------------------- 700G - 1000G 157 1,491.50 1,617.10
----------------------------------------------- 1000G - 1500G 36 342.00 370.80

FROZEN CUTTLE FISH (GRADE AA)

----------------------------------------------- 100G - 200G 39 370.50 401.70
----------------------------------------------- 200G - 300G 33 313.50 339.90
----------------------------------------------- 300G - 500G 54 513.00 556.20
----------------------------------------------- 500G - 700G 131 1,244.50 1,349.30
----------------------------------------------- 700G - 1000G 127 1,206.50 1,308.10
----------------------------------------------- 1000G - 1500G 44 418.00 453.20

SUB TOTAL - 1 1,803 17,128.50 18,570.90

2. FROZEN SQUID
----------------------------------------------- 8-10 (200G-300G) 363 3,448.50 3,738.90
----------------------------------------------- 10-12 (300G-500G) 197 1,871.50 2,029.10
----------------------------------------------- 12-14 (500G-700G) 165 1,567.50 1,699.50
----------------------------------------------- 14 UP (700G UP) 72 684.00 741.60

SUB TOTAL - 2 797 7,571.50 8,209.10

GRAND TOTAL 2,600 24,700.00 26,780.00

Yours Faithfully,
PT. LAUTAN PERSADA