No.

: 7557522
REPUBLIK INDONESIA
KEMENTERIAN PERTANIAN
BADAN KARANTINA PERTANIAN
KT - 12

SERTIFIKAT KESEHATAN TUMBUHAN ANTAR AREA

Nomor 2023.2.0302.0.K12.K.001737

Berdasarkan Undang-Undang Nomor 21 Tahun 2019 tentang Karantina Hewan, Ikan, dan
Tumbuhan serta hasil tindakan karantina tumbuhan, menyatakan bahwa media pembawa tersebut
di bawah ini:
1. Nama umum/dagang/kode HS: APEL, ........................................................................................................
PIR, ANGGUR, JERUK, KELENGKENG
2. Nama ilmiah**): ................................................................................................................................
Malus Domesticum;Pyrus Communis;Vitis Vinifera;Citrus Spp;Nephelium Longana.
3. Bentuk dan jumlah): .........................................................................................................................
BUAH = 25.000 KILOGRAM
4. Bahan pembungkus/kemasan: .........................................................................................................
CARTON / JUMLAH KEMASAN: 1250
5. Tanda/merek pada pembungkus/kemasan: LAKU5803303 .....................................................................................
6. ==========
Jumlah dan nomor peti kemas**): ....................................................................................................
7. Nama dan alamat pengirim: .............................................................................................................
PT.SUMBER KARYA DIGITAL
..........................................................................................................................................................
CILINCING - JAKARTA UTARA
..........................................................................................................................................................
PT. SUMBER KARYA DIGITAL
8. Nama dan alamat penerima: ............................................................................................................
..........................................................................................................................................................
BITUNG - MANADO
..........................................................................................................................................................
9. Tujuan pengeluaran: ........................................................................................................................
1-KONSUMSI
10. Area asal dan tempat pengeluaran: ................................................................................................
KOTA JAKARTA UTARA/PELABUHAN TANJUNG PRIOK
11. Area tujuan dan tempat pemasukan: ..............................................................................................
KOTA BITUNG/BITUNG
12. Jenis dan nama alat angkut: ...........................................................................................................
KM. MERATUS MEDAN 1/-
13. Tanggal berangkat: .........................................................................................................................
13 November 2023

telah memenuhi semua persyaratan yang ditetapkan bagi pengirimannya ke area tujuan serta
bebas dari organisme pengganggu tumbuhan karantina dan organisme pengganggu tumbuhan
penting.
KETERANGAN TAMBAHAN**)
................................................................................................................................................................
=================
................................................................................................................................................................
................................................................................................................................................................

PERLAKUAN**)
1. =================
Tanggal: ............................................................................................................................................
2. =================
Jenis perlakuan: ................................................................................................................................
3. =================
Jenis pestisida/bahan yang digunakan: ............................................................................................
4. =================
Konsentrasi/dosis: .............................................................................................................................
5. =================
Durasi dan temperatur: .....................................................................................................................
6. =================
Informasi tambahan: .........................................................................................................................

DKI JAKARTA
Diterbitkan di: .......................................
13 November 2023
Pada tanggal: .......................................
Pejabat Karantina Tumbuhan

..............................................................
HENDRA SOPIYAN, SP
NIP 197605142009121003
........................................................
*) Diisi bila perlu dan/atau memungkinkan.