No. Dokumen : FR.PKV.

01
BALAI STANDARDISASI DAN PELAYANAN
Edisi :2
JASA INDUSTRI
PADANG Revisi :0
Efektif : 11 Mei 2022
FORMULIR KERJA Halaman : 1 dari 1

Subjek : Surat Permohonan dan Kaji Ulang Pengujian

1. Tanggal Permohonan : ..............................................................................................................

2. Nama / Perusahaan : ..............................................................................................................
3. Alamat Lengkap : ..............................................................................................................
4. No. Telp / HP Kantor : ...............................................................................................................
5. Komoditi : ...............................................................................................................
6. Jumlah : ...............................................................................................................
7. Kode Contoh : ...............................................................................................................
8. Standar Acuan : ...............................................................................................................
9. Nama Pengantar : ...............................................................................................................
10. No. HP : ...............................................................................................................
11. Parameter yang akan diuji : ...............................................................................................................
No. Parameter Jumlah Harga Satuan (Rp) Total (Rp) Rekomendasi*

Total Pembayaran
Keterangan Kondisi Sampel :

Catatan :
 Beri tanda √ jika metoda uji, peralatan, personil, bahan kimia, QC/QA dan kondisi akomodasi memenuhi persyaratan
 Beri tanda X jika metoda uji, jika salah satu option tersebut tidak memenuhi

Padang, ....................................
Verifikasi Kaji Ulang Pemohon

( ................................... ) ( .................................. )
PJ. Teknis