FORM TANK – 001

CALTEX___
INSPECTION REPORT
PT. Caltex Pacific Indonesia Construction of Sand Plant and Sand Pan Facilities
CGS-5 (Package 1) in DSF Duri PT. META EPSI Engineering

VACCUM TEST RECORD

Client : Date :
Project : Location :
Description : Report No :
Sketch :

PART NAME PART AREA PRESSURE HOLDING TIME REMARK

NO

Prepared by Checked by Approved by

___________________ ___________________ ___________________

DATE : DATE : DATE :
FORM TANK – 002

CALTEX___
INSPECTION REPORT
PT. Caltex Pacific Indonesia Construction of Sand Plant and Sand Pan Facilities
CGS-5 (Package 1) in DSF Duri PT. META EPSI Engineering

PLUMBNESS CHECK RECORD

Client : Date :
Project : Location :
Description : Report No :
Sketch :

4
C

B D
3

A E
2 High of tank

H
F
G 1

Spec: High as per plate : ………………….

Total High plate : 6 x 1.829 = 10.974 mm Tolerance : 54.87 mm

MEASUREMENT ACTUAL
PLAN REMARK
POINT 1 2 3 4

RESULT : ACCEPTABLE UN-ACCEPTABLE

Prepared by Checked by Approved by

___________________ ___________________ ___________________

DATE : DATE : DATE :
FORM TANK – 003

CALTEX___
INSPECTION REPORT
PT. Caltex Pacific Indonesia Construction of Sand Plant and Sand Pan Facilities
CGS-5 (Package 1) in DSF Duri PT. META EPSI Engineering

HYDROSTATIC TEST REPORT

Client : Date :
Project : Location :
Description : Report No :
Sketch :

Course 6

Course 5

Course 4
Height of water
Course 3

Course 2

Course 1

Method : fresh water

Starting WATER LEVEL Height of water HOLDING TIME RESULT

1
2
3
4
5
6

RESULT : ACCEPTABLE UN-ACCEPTABLE

Prepared by Checked by Approved by

___________________ ___________________ ___________________

DATE : DATE : DATE :
FORM TANK – 004

CALTEX___
INSPECTION REPORT
PT. Caltex Pacific Indonesia Construction of Sand Plant and Sand Pan Facilities
CGS-5 (Package 1) in DSF Duri PT. META EPSI Engineering

LEAK TEST REINFORCEMENT

Client : Date :
Project : Location :
Description : Report No :
Sketch :

Method : Bubble soap

Description Joint Identification Pressure Result Remark

Prepared by Checked by Approved by

___________________ ___________________ ___________________

DATE : DATE : DATE :
FORM TANK – 005

CALTEX___
INSPECTION REPORT
PT. Caltex Pacific Indonesia Construction of Sand Plant and Sand Pan Facilities
CGS-5 (Package 1) in DSF Duri PT. META EPSI Engineering

DISTORSION WELDING

Client : PT. Caltex Pacific Indonesia Date :

Project :Sand Removal facilities Location : CGS – 05
Description : Report No :
Sketch :

Dimension
Description Area of distortion Remark
Out (mm) In (mm)

Prepared by Checked by Approved by

___________________ ___________________ ___________________

DATE : DATE : DATE :
FORM TANK – 006

CALTEX___
INSPECTION REPORT
PT. Caltex Pacific Indonesia Construction of Sand Plant and Sand Pan Facilities
CGS-5 (Package 1) in DSF Duri PT. META EPSI Engineering

ROUNDNESS , ORIENTATION CHECK RECORD

Client : Date :
Project : Location :
Description : Report No :
Sketch :
1. ROUNDNESS

C G Measurement
Diameter Actual (cm) Remarks
Point
A-B C-D E-F G-H
Top/end (cm) (cm) (cm) (cm)
A B Middle
Bottom

H D

2. ORIENTATION NOZZLE

Position
Description Symbol Remark
Plan Actual Plan Actual Plan Actual

Prepared by Checked by Approved by

___________________ ___________________ ___________________

DATE : DATE : DATE :
FORM TANK – 007

CALTEX___
INSPECTION REPORT
PT. Caltex Pacific Indonesia Construction of Sand Plant and Sand Pan Facilities
CGS-5 (Package 1) in DSF Duri PT. META EPSI Engineering

THICKNESS RECORD

Client : Date :
Project : Location :
Description : Report No :
Sketch :

#A #B

#E # F
#D #C THICKNESS :
REQ’D : PLATE
EQUIPMENT USED : UT FLOW DETECTOR

NO DESCRIPTION A B C D E F AVARAGE RESULT

Prepared by Checked by Approved by

___________________ ___________________ ___________________

DATE : DATE : DATE :
FORM TANK – 008

CALTEX___
INSPECTION REPORT
PT. Caltex Pacific Indonesia Construction of Sand Plant and Sand Pan Facilities
CGS-5 (Package 1) in DSF Duri PT. META EPSI Engineering

ROLLING PLATE RECORD

Client : Date :
Project : Location :
Description : Report No :
Sketch :
R3

R2 R4

R5
R1
R6

THICKNESS :
TOLERANCE : REQ’D : SHELL PLATE

NO DESCRIPTION R1 R2 R3 R4 R5 R6 DEVIATION RESULT

Prepared by Checked by Approved by

___________________ ___________________ ___________________

DATE : DATE : DATE :
FORM TANK – 009

CALTEX___
INSPECTION REPORT
PT. Caltex Pacific Indonesia Construction of Sand Plant and Sand Pan Facilities
CGS-5 (Package 1) in DSF Duri PT. META EPSI Engineering

PEAKING/ BANDING CHECK RECORD

Client : Date :
Project : Location :
Description : Report No :
Sketch :

900 COURSE 6
450
1350 COURSE 5

COURSE 4
00 1800
COURSE 3

COURSE 2
3200 2250
COURSE 1
2700

MEASUREMENT : CONVEX RULE

INSPECTION RECORD OF PEAKING BEFORE, AFTER WELDING, MACHINE, CUTTING

DEVIATION
NO COURSE & PLATE NUMBER ORIENT REMARK
PREWELD POSTWELD

RESULT : ACCEPTABLE UN-ACCEPTABLE

Prepared by Checked by Approved by

___________________ ___________________ ___________________

DATE : DATE : DATE :
FORM TANK – 010

CALTEX___
INSPECTION REPORT
PT. Caltex Pacific Indonesia Construction of Sand Plant and Sand Pan Facilities
CGS-5 (Package 1) in DSF Duri PT. META EPSI Engineering

LIQUID PENETRANT EXAMINATION RECORD

Client : Date :
Project : Location :
Description : Report No :
Sketch :

APPLICABLE CODE : ASME SEC. V , STANDARD MATERIAL SPEC : PLATE ASTM A 36

LOCATION OF EXAMINATION : EGDE OF BOTTOM PLATE PENETRAN TIME :
TYPE OF PENETRAN : SPRAYING TYPE OF DEVELOPING : DRY DEVELOP
METHOD USED : MATERIAL THICK : 10 MM
TESTING OF TEMP : 320 CELCIUS WELDING PROCESS : SMAW

NO AREA OF LIQUID RESULT REJECT RESULT REMARK

RESULT : ACCEPTABLE UN-ACCEPTABLE

Prepared by Checked by Approved by

___________________ ___________________ ___________________

DATE : DATE : DATE :
FORM TANK – 011
INSPECTION REPORT
Bottom Tanki 5-T-01 PT. PERTAMINAA Refinery Unit
PERTAMINA VII KASIM
RU-VII KASIM

BOTTOM ARRANGEMENT (MAPPING)

Client : PT. PERTAMINA (Persero)

Date : 09-12-12016
Refinery Unit VII KASIM
Project : Fabrikasi Repair Tanki 5-T-01 & 5-T-02 Location : PT. PERTAMINA RU VII KASIM
Description : Report No : 01/QC/JKB

00

V1

V2 V3

V4 V5 V6

2700 90 0
V7 V8

V9 V10 V11

V12 V13

V 14

1800

NOTE :
V = NORTH DIRECTION
H = WEST DIRECTION

Checked by Approved by
Prepared by

________________ ___________________
___________________
___ DATE :
DATE :
DATE :
FORM TANK - 012

CALTEX___
INSPECTION REPORT
PT. Caltex Pacific Indonesia Construction of Sand Plant and Sand Pan Facilities
CGS-5 (Package 1) in DSF Duri PT. META EPSI Engineering
INSPECTION TYPE : PROJECT NO. : ____________________________
REPORT NO. : ____________________________
RADIOGRAPHY SPOT
LOCATION : ____________________________
(NDT MAP)
DATE : ____________________________

Sketch
S-R

N H5
V7
H4
H2
V6

H3

H2 .

T1

H1 V5 H1 .

V1 V2 V3 V4 B-S .
Reference point for horizontal RT : Manhole 0

POSITION INSPECTION
NO NUMBER OF SPOT WELDER STEMP
WELDING RT RT 1 RT 2

.RESULT ACCEPTABLE UN-ACCEPTABLE.

REVIEWED/WITNESSED BY INSPECTED BY PREPARED BY
COMPANY INSPECTOR QC

___________________ ___________________ ___________________

DATE : DATE : DATE :
FORM TANK – 013

CALTEX___
INSPECTION REPORT
PT. Caltex Pacific Indonesia Construction of Sand Plant and Sand Pan Facilities
CGS-5 (Package 1) in DSF Duri PT. META EPSI Engineering

ROOF ARRANGEMENT (MAPPING)

Client : Date :
Project : Location :
Description : Report No :

V1

V3 V5

H5 H2 H1 H4

V4 V6

V2

NOTE :
V = VERTICAL DIRECTION WELDING
H = HORIZONTAL DIRECTION WELDING

Prepared by Checked by Approved by

___________________ ___________________ ___________________

DATE : DATE : DATE :
FORM TANK – 014

CALTEX___
INSPECTION REPORT
PT. Caltex Pacific Indonesia Construction of Sand Plant and Sand Pan Facilities
CGS-5 (Package 1) in DSF Duri PT. META EPSI Engineering

SHELL ARRANGEMENT (MAPPING)

Client : Date :
Project : Location :
Description : Report No :
Sketch
S-R .
COURSE 6 V6A V6B V6C V6D V6E

H5 .
COURSE 5 V5A V5B V5C V5D V5E
H4 .
COURSE 4
V4A V4B V4C V4D V4E

H3 .
COURSE 3 VAVV
V3A V3B V3C V3D V4E
H2 .

COURSE 2 V2A V2B V2C V2D V2E

H1 .

COURSE 1 V1A V2B V3C V4D V5E

B-S .
0

Reference point for horizontal RT : Manhole

RESULT ACCEPTABLE UN-ACCEPTABLE.

REVIEWED/WITNESSED BY INSPECTED BY PREPARED BY
COMPANY INSPECTOR QC

___________________ ___________________ ___________________

DATE : DATE : DATE :
FORM TANK – 015

CALTEX___
INSPECTION REPORT
PT. Caltex Pacific Indonesia Construction of Sand Plant and Sand Pan Facilities
CGS-5 (Package 1) in DSF Duri PT. META EPSI Engineering

WELDING REPORT

Client : Date :
Project : Location :
Description : Report No :
PLATE WELDER WELD VISUAL INSPECTION
NO HEAT NUMBER
NUMBER STAMP AREA CONTOUR DEFECT RESULT

RESULT ACCEPTABLE UN-ACCEPTABLE.

REVIEWED/WITNESSED BY INSPECTED BY PREPARED BY
COMPANY INSPECTOR QC

___________________ ___________________ ___________________

DATE : DATE : DATE :
FORM TANK – 016

CALTEX___
INSPECTION REPORT
PT. Caltex Pacific Indonesia Construction of Sand Plant and Sand Pan Facilities
CGS-5 (Package 1) in DSF Duri PT. META EPSI Engineering

HOLIDAY TEST REPORT

Client : PT. CPI Date :

Project :Sand Removal Facilities Location : CGS – 05
Description : Report No :
EQUIPMENT TYPE : WET SPONGE COATING MATERIAL
EQUIPMENT MODEL : TINKER M-1 PRIMER : TANK GUARD RED
TEST VOLTAGES : 67.50 VOLTAGE 2 ND COAT : TANK GUARD LIGHT RED
COATING THICKNESS : 250 – 300 MICRONE MANUFACTURER : JOTUN
RESULT RESULT FINAL
NO DESCRIPTION REMARK
1 ST 2 ND JUDGMENT

NOTE :

RESULT ACCEPTABLE UN-ACCEPTABLE.

REVIEWED/WITNESSED BY INSPECTED BY PREPARED BY
COMPANY INSPECTOR QC

___________________ ___________________ ___________________

DATE : DATE : DATE :

FORM TANK – 000

CALTEX___
INSPECTION REPORT
 PT. Caltex Pacific Indonesia
Construction of Sand Plant and Sand Pan Facilities
CGS-5 (Package 1) in DSF Duri PT. META EPSI Engineering

NON-CONFORMANCE REPORT

Client : Date :
Project : Location :
Description Report No :
CONT/ SUB CONT/ VENDOR CATEGORY
NCR HOLD TAG

DRAWING / DOC (S) LOCATION SPECIFICATION

ITEM DESCRIPTION

INITIATED BY REVIEWED BY
DESCRIPTION OF THE NON CONFORMANCE
(Included a description of the requirement that was not met)

CORRECTION ACTION BY :
DIPOSITION
(attachment)
Est CORRECTION COMMENCE DATE :

COMPLETION ESTIMATED : DAYS/ WEEK

COMPANY COMMENT :

DATE :
PROJ. ENG. : DATE :

DISPOSITION WORK COMPLETE SIGNED : DATE :

ACTION VERIFEID, ISPECTED AND CLOSED
VERIFIED BY INSPECTED/ CHECKED BY CLOSED BY
(Company)

DATE : DATE : DATE :

FORM TANK – 000

CALTEX___
INSPECTION REPORT
PT. Caltex Pacific Indonesia Construction of Sand Plant and Sand Pan Facilities
CGS-5 (Package 1) in DSF Duri PT. META EPSI Engineering
 NON-CONFORMANCE REPORT LOG

Client : Date : Page : of

Project : Location :
Description Report No :
NCR
HOLD/TAG DATE OPENED DATE CLOSED DESCRIPTION NON CONFORMANCE
NO

NON CONFORMANCE REPORT

PROCEDURE
 1. SCOPE

This procedure describe the method and responsibilities for controlling nonconforming item to prevent
their in advertent use or installation .
This procedure provides for identification, document, evaluation, disposition, notification, segregation,
and inspection of these nonconforming items.

2. DEFINITION
The following word shall have the meaning indicated when used here in :
COMPANY PT. Caltex Pacific Indonesia, as the ultimate user and owner
MIGAS Indonesia Government Body responsible for issuing approval and licenses for Oil and gas facilities
THIRD PARTY Third party Inspection Company approval and appointed to act on behalf of MIGAS
CONTRACTOR Engineering, procurement and construction CONTRACTOR selected by CPI to perform the detailed
design, procurement and construction of project
VENDOR Supplier, fabricator and /or original equipment manufacture awarded a purchase order by the
CONTRACTOR and/ or CPI furnish materials or equipment.
 CMT Construction Management Team , a CPI construction Group.

3. PURPOSE
In order to bring to everyone’s attention, item which deviated or are outside of project requirements as defined in
whole therein. This control procedure for nonconforming items deals with the treatment and corrective action, to prevent
misuse and any reoccurrence of the same type of non conforming item whether it is during design, manufacturing,
fabrication or construction execution.

4. CONTROL
4.1 . When any deviation from project requirement is defected, it shall be immediately notified by means of a report
to the appropriated department responsible for the activity or supply of the non conforming item, Where
requirement the item shall be put on hold and identification by means of product marking or affixing a hold tag
to preclude inadvertent use or installation.
4.2. Non conforming item shall be judge and categorized into what is deemed as being minor and major non
conforming.
4.3. The following examples of non conformance shall be defined as being MAJOR :
- Where the non conformance deviates from statutory regulations
- Where it causes major design changes, including cases of “ Use – As – Is” basis
- When the inspection item and or activity is not in accordance with the project international codes
and / or Standard
- When there a failure to comply with the requirements of the project approval test and inspection
plan, when the activity and or item is categories as being a HOLD point, but not treated as such.
- Where the non conformance item can not be easily rectified without returning the item to original
place of manufacturer, or where corrective measure have to be performance by supplier or suppliers
representative at the job site in order to bring thr item back into compliance.
- Safety violations which endanger life and are hazardous to the local community. Marine and or wild
life, with particular reference to wild animal migration activities for the onshore portion of the
project.

4.4. In general MINOR non-conformance shall be defined as those item which can easily be rectified at site.
Typical Minor non conformance are as describe below:
 - normal construction field engineering changes based on construction ability, equivalent material
substitution, minor piping route changes, etc
- Mis-Interpretation of drawing resulting in corrected fabrication or installation, which can easily be
rectified.
- Deviation from the project specification, but where the end result is still acceptable .
- Failure to followed exactly as specified the installation procedure provided by engineering or
VENDOR recommendation, were the final result however does not have an overall adverse effect to
the operational usage of equipment and / or component part etc, and does not invalidate
manufacturing warranties.
Where conflicts occur as to whether an item is of a MAJOR or MINOR non conformance, the final decision in all cases
shall be made by the clients project Chief Engineer.

5.0 RESPOSIBILITY FOR IDENTIFYING NON CONFORMANCES

5.1. contractor will issue non conformance report on self perform work when applicable.
5.2. Non conformance report are usually initiated by inspection personnel : however, anyone may initiate an
NCR
5.3. The Sub contractor have the first responsibility for the identification, control, and disposal of non
conformance item within their scope of work. Contractor will issue a Non conformance report when the
sub contractor has not issued one. It is not necessary to have more than one non conformance report
active on the identical nonconformance condition.

6.0 CONTROL OF NON CONFORMANCE ITEMS

The Site Manager will take measures to provide holding areas or other methods for segregation nonconformance
items to prevent un-authorized use, mixing with conforming items or incorporating into future construction. Where physical
segregation is not practical, tagging, marking, or other positive means of identification is acceptable. The quality control
Manager may elected to use :HOLD” tags/stickers.

7.0 QUALITY CONTROL MANAGER

7.1. Evaluate the report to determine that the described condition is a valid nonconformance report active on
the identical nonconformance condition. If a construction sub construction has issued the NCR, it should
not duplicated by contractor.
7.2. Assign a unique number to the report and enter the number here and on the “Non conformance Report
Log”
7.3. If hold the tag is need, enter the NCR number as the hold tag number and have the hold tag installed on
the item. If tag is not to be used, enter N/ A.
7.4. forward of copy to the Company representative.

8.0 PROJECT ENGINEER

8.1 Evaluated the proposal disposition, modify if necessary, or enter the disposition.
8.2 If the non conformance condition will not be corrected in full conformance with the applicable
specification, obtain the company Chief Engineer to approval .
8.3 If the non conformance condition will not be corrected in full conformance with the applicable
specification , obtain the Company representative to comment approval.
 9.0 SITE MANAGER

Upon received of the approval NCR disposition, perform the applicable construction action specification in the NCR
disposition. Perform the applicable construction action specified in the NCR disposition . Sign the off for completion of
disposition on the copy and forward it to the Quality control Manager to serve as notification of readiness for close
inspection.

10.0 QUALITY CONTROL MANAGER

10.1 Upon verification of satisfactory completion of the disposition, sign and date
10.2 Sand the verified and completed action NCR to company representative to close out.

11.0 ATTACHMENT

Non conformance Report Form

Non conformances report Log.