PT.

REZEKI BORNEO SEBUKU

Jobsite Indexim Coalindo, Kutai Timur, Kalimatan Timur

No Surat : 536/RBS/IC/ESCORT/XI/2023
Lampiran : 1 (Daftar Visitor/Driver)
Perihal : Permohonan 1 x izin lintas Escort Bermuatan Sparepart

Kepada Yth
Kepala Teknik Tambang
PT Indexim Coalindo
Di Site Kaliorang

Dengan hormat,

Sehubungan dengan rencana melakukan Escort kendaraan di wilayah kerja PKP2B PT Indexim
Coalindo, kami mengajukan permohonan dengan informasi sbb;

Hari : 10 November 2023

Jalur : KM. 14 – KM.29 Area Workshop PT. RBS
Waktu Pelaksanaan : 07:00 WITA - Selesai
Jumlah Kendaraan : 2 Unit LV ( Escort Commander dan Escort Tail )
Kendaraan yang di Escort : 1 x Unit mobil Truck bermuatan Sparepart
Escort dilakukan :1 Kali Truck KT 8465 NS
( 1 kali escort maksimal 3 unit )

Selama melintas kami akan mengikuti aturan-ketentuan di site PT Indexim Coalindo dan melengkapi
APD (Safety Helmet, Glasses, Shoes, Reflector Jacket dll) sendiri, serta kelengkapan kendaraan yang
melakukan escort telah lulus komissioning PT. Indexim Coalindo.

Atas perhatian dan kerjasamanya, kami ucapkan terimakasih

Kaliorang, 8 Oktober 2023

Hormat Kami Mengetahui, Disetujui Oleh,

DHA
DHA (Nov 9, 2023 13:37 GMT+8)

Criwillyam Nanang Yusuf Eddy S. Kaban Hendrato A. Gunawan

DH DIC Mitra PJO Mitra kerja Sr. Project Manager KTT / GM Site
 PT. REZEKI BORNEO SEBUKU
Jobsite Indexim Coalindo, Kutai Timur, Kalimatan Timur

DAFTAR PERSONIL

No Nama Perusahaan Jabatan Keterangan*

1 Wahyu Novi Sanjaya PT. RBS Driver Fit to work

10

*) fit to work

Lampirkan :
1. STNK masih berlaku
2. Pajak masih berlaku
3. Surat Jalan atau Daftar Manifest Muatan
4. SIM dari pengemudi masih berlaku
 PT. REZEKI BORNEO SEBUKU
Jobsite Indexim Coalindo, Kutai Timur, Kalimatan Timur

Rincian Schedule Escort

No. Tanggal Waktu Keterangan

1. 10 Oktober 2023 Pkl. 07.00- 17.00 Escort Unit Mobil Bermuatan Spare Part
2.
3.
4.
5.
6.
PT. REZEKI BORNEO SEBUKU
Jobsite Indexim Coalindo, Kutai Timur, Kalimatan Timur
PT. REZEKI BORNEO SEBUKU
Jobsite Indexim Coalindo, Kutai Timur, Kalimatan Timur
PT. REZEKI BORNEO SEBUKU
Jobsite Indexim Coalindo, Kutai Timur, Kalimatan Timur
PT. REZEKI BORNEO SEBUKU
Jobsite Indexim Coalindo, Kutai Timur, Kalimatan Timur
PT. REZEKI BORNEO SEBUKU
Jobsite Indexim Coalindo, Kutai Timur, Kalimatan Timur
536. Surat Escort Truk Bermuatan Sparepart PT
RBS
Final Audit Report 2023-11-09

Created: 2023-11-08

By: eSign Project (esign.project@indexim.co.id)

Status: Signed

Transaction ID: CBJCHBCAABAAiEm2pHpOcFMc0MQ4n526illkRz85w0Mq

"536. Surat Escort Truk Bermuatan Sparepart PT RBS" History

Document created by eSign Project (esign.project@indexim.co.id)
2023-11-08 - 11:09:38 PM GMT- IP address: 103.160.150.66

Document emailed to eddy.kaban@indexim.co.id for signature

2023-11-08 - 11:10:26 PM GMT

Email viewed by eddy.kaban@indexim.co.id

2023-11-09 - 1:49:13 AM GMT- IP address: 104.47.110.62

Signer eddy.kaban@indexim.co.id entered name at signing as Eddy Salmon K

2023-11-09 - 1:50:59 AM GMT- IP address: 103.160.150.66

Document e-signed by Eddy Salmon K (eddy.kaban@indexim.co.id)

Signature Date: 2023-11-09 - 1:51:01 AM GMT - Time Source: server- IP address: 103.160.150.66

Document emailed to dimas.hanggono@indexim.co.id for signature

2023-11-09 - 1:51:03 AM GMT

Email viewed by dimas.hanggono@indexim.co.id

2023-11-09 - 5:37:21 AM GMT- IP address: 104.47.110.62

Signer dimas.hanggono@indexim.co.id entered name at signing as DHA

2023-11-09 - 5:37:35 AM GMT- IP address: 103.160.150.66

Document e-signed by DHA (dimas.hanggono@indexim.co.id)

Signature Date: 2023-11-09 - 5:37:37 AM GMT - Time Source: server- IP address: 103.160.150.66

Document emailed to didik jati mulyanto (didik.jati@indexim.co.id) for signature

2023-11-09 - 5:37:38 AM GMT
Email viewed by didik jati mulyanto (didik.jati@indexim.co.id)
2023-11-09 - 5:55:54 AM GMT- IP address: 104.47.110.62

Document e-signed by didik jati mulyanto (didik.jati@indexim.co.id)

Signature Date: 2023-11-09 - 5:57:30 AM GMT - Time Source: server- IP address: 103.160.150.66

Agreement completed.
2023-11-09 - 5:57:30 AM GMT