PRIMA NIRBHAYA MSE 2.

03
Form

Contact Person Name: Telp:

PT KALTIM PRIMA COAL - MINING OPERATION DIVISION OPERATOR TRAINING

PERMOHONAN KIMPER/KIMPER APPLICATION
L/VEHICLE, L/TRUCK, PIT ACCESS (IJIN AKSES PIT) / HEAVY EQUIPMENT (ALAT BERAT)
Nama Calon Vijaya Kumar D Apakah untuk menggantikan seseorang? Is this replacing someone?
Name of Applicant YES NO
B/N 110107 Siapa/Who
Departemen Name / ID
Department PLM CATATAN/NOTE: Untuk penggantian harus menyertakan:
- Kimper Asli, atau.
Perusahaan - Bukti penyerahan Kimper Asli dari Kimper Section.
Company DH
Posisi JUSTIFIKASI KIMPER BARU JUSTIFICATION FOR NEW KIMPER
Position TECHNICAL ADVISOR Need to do the trial test after maitenance
Alat yang akan ditest
Equipment for test R9350 Backhoe, R9100 Backhoe

Dengan ini mengajukan/I wish to apply for:

a. Pelatihan/Training Sudahkah Anda memiliki Kimper KPC sebelumnya? Do you currently hold or have you ever held a
KPC Kimper? YES NO
b. Ujian/Test Pekerja Shift/
c. Perubahan status kimper/Skill Upgrade Shift Worker? 2 shift
Alat/equipment :
Heavy equipment YES NO 3 shift
d. Kimper trasnfer
Disetujui oleh/Approved by:
Contractor Manager Contractor Custodian HSE Coord. Contractor Custodian Manager
(Untuk karyawan labour suplly ditandatangani oleh
manager labour supply dan manager pengguna)

Signature : Signature : Signature :

Name: HOTMONANG F. SITANGGANG Name: Name:
Date: Date: Date:

Contract Custodian Manager Contract Custodian HSE Coord. MOD HSE Superintendent

Signature : Signature : Signature :

Name: Name: JMN TRIANTARIKSA TJANDRA Name:
Date: Date: Date:
GM Mining Operations Kepala Teknik

Data populasi kendaraan tambang

Signature : Signature : (Mining Access/MA) dan Kimper Pit Access (PA)
Name: Name:
Date: Date: LV / LT-MA :
Applikasi ini harus disetujui oleh Manajer keatas. This application must be approved by a Manager or above. KIMPER-PA:
Untuk mendapatkan Kimper, applikasi ini harus dilengkapi dengan: /To be approved for a Kimper, you must provide the following Diperiksa oleh/Checked by:
records: Admin Trainer
1. Salinan SIM Polisi yang sesuai dan masih berlaku, kecuali alat berat./ Copy of current Police SIM or International License for
expats, except HE.
2. Telah mengikuti program Pengenalan Keselamatan KPC. /Proof of attendance of a recent KPC Induction.
3. Telah mengikuti briefing mengenai Peraturan Tambang. /Pit Rules briefing.
4. Telah mengikuti briefing Radio Communication sistem trunking./Radio Communication Trunking System briefing
5. Khusus pengetesan Crane, harus mengikuti training Basic Slinging & Lifting. /For Crane testing, the applicant shall attend Basic
Slinging & Lifting.
6. Transfer kimper harus menyerahkan surat PHK/Tidak keberatan pindah perusahaan lama. Rekomendasi perusahaan baru dan ID/
Kimper lama dan copy MCU./For KIMPER transfer require termination certificate/ permission to out letter from origin company,
recommendation letter from new company, old ID, and copy of MCU.

Document Title Approved By Effective Date Uncontrolled Document

Permohonan Kimper Luar Pit/Kimper Application Non Pit Equipment GM HSES 01 October 2020 When Printed or Out of HSE Info

Doc Registration No. Version Next Review Due

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HSE_KPC_KPC_MSE2.03_DOC_FRMb_002 3.0 01 October 2025