Form Survey

REQUEST FOR INSPECTION (RFI)
PROJECT :
SERONGGA (KELUMPANG HILIR) COAL TERMINAL
KOTA BARU, KALIMANTAN SELATAN
Doc No. : WRK-QAS-RFI-SRG-090-

Date :
Submitted By : PT.WIKA REKAYASA KONTRUKSI
Attn. :
To : PT.DUA SAMUDRA PERKASA
Attn : GENDIS.P
Dear Sirs,
We would to have your presence for inspection according to the following schedule.
Please be informed that the following items are in order and are ready for inspection/witness.
Date & Time
Location
Inspection Item
Element
Sub Item / Reference Date / Time of Inspection
Comments :
Acceptable, you may proceed WITH/WITHOUT our attendance.
Please reschedule the witness/inspection date
Not acceptable, you shall rectify item and resubmit request for inspection
Others :
Name / Signature of PT.DSP : Date / Time :
Name / Signature of PT.WRK : Date / Time :
Name / Signature of Subcont / Vendor : Date / Time :

PROYEK PEKERJAAN GUDANG PUPUK KAPASITAS 15000 TON
BATULICIN, KALIMANTAN SELATAN
DATA SURVEY
Subject
Date
Location
Surveyor
ELEVATION DISTANCE
No. POINT BM BS FS HI REMARKS
BEFORE AFTER (mm)
Note :
PT. KODECO ARGOJAYA MANDIRI PT. WIJAYA KARYA REKAYASA KONSTRUKSI

APPROVED BY. APPROVED BY. REVIEWED BY. PREPARED BY.
Print Name
Signature
Date
PROYEK PEKERJAAN PENUTUP VOID CONCRETE JETTY 1500 DWT
DATA SURVEY
Subject
Date
Location
Surveyor
ELEVATION DISTANCE
No. POINT BM BS FS HI REMARKS
BEFORE AFTER (mm)
Note :
PT. DUA SAMUDERA PERKASA PT. WIJAYA KARYA REKAYASA KONSTRUKSI

APPROVED BY. APPROVED BY. REVIEWED BY. PREPARED BY.
Print Name
Signature
Date
PROYEK PEMBANGUNAN COAL TERMINAL CAP 2 x
12 MTPY
DOKUMENTASI PRE - POURING STG-QAS-ISP-045-056

INSPEKSI
Pre-
Pouring Concrete
Doc. No. : STG-QAS-ISD-01-008 Q 045
Subject Inspeksi Pre-Pouring Concrete Date

Service No. Bypass Hopper Line 1A F3 (fc28) Inspection No. STG-QAS-ISP-045-009
Location Line 1 Revision No.
Sub-Cont. Ref. Drawing No. WRK/C/DD/02
Accepted
NO INSPECTION ITEM Date Sign Remark
Yes No
1 Diameter & quantity of rebar
2 Diameter & distance of Stirrup
3 Ties at Rebar
4 Overlap Splaccing
5 Concrete Cover / Conrete decking

Installation of embedded all ( anchor bolts,
6 pipes, angle, insert plates etc )
7 Ikatan kawat bendrat
8 Material quality (shape & surface)
9 Dimension ( Widht, length, height)
10 Shoring & support
11 Tiltness of the vertical tolerance
12 Straightness of line of the formwork
13 Elevation (Top Cor)
14 Koordinat
15 Rectangularity of formwork
16 Form Oil Usage
17 Cleanliness
Note :
PT. WIKA REKAYASA KONSTRUKSI PT. DUA SAMUDERA PERKASA

PREPARED BY. CHEKED BY. APPROVED BY.
Print Name
Signature
Date
INSPEKSI
Pre-
Pouring Concrete
Subject Inspeksi Pre-Pouring Concrete Date 07 Agustus 2022

Service No. Dump Hopper Line 1 A (fc28) Inspection No. STG-QAS-ISP-045-010
Accepted
Yes No
3 Ties at Rebar
4 Overlap Splaccing

14 Koordinat
16 Form Oil Usage
17 Cleanliness
Note :

Print Name
Signature
Date
INSPEKSI
Pre-
Pouring Concrete

Service No. Bypass Hopper Line 1A F5 (fc28) Inspection No. STG-QAS-ISP-045-011
Accepted
Yes No
3 Ties at Rebar
4 Overlap Splaccing

14 Koordinat
16 Form Oil Usage
17 Cleanliness
Note :

Print Name
Signature
Date
INSPEKSI
Pre-
Pouring Concrete

Service No. Pile Cap Radial Staker Line 1A (fc28) Inspection No. STG-QAS-ISP-045-012
Accepted
Yes No
3 Ties at Rebar
4 Overlap Splaccing

14 Koordinat
16 Form Oil Usage
17 Cleanliness
Note :

Print Name
Signature
Date
INSPEKSI
Pre-
Pouring Concrete

Service No. Pile Cap BC05 Line 1A/Transfer Tower (fc28) Inspection No. STG-QAS-ISP-045-013
Accepted
Yes No
3 Ties at Rebar
4 Overlap Splaccing

14 Koordinat
16 Form Oil Usage
17 Cleanliness
Note :

Print Name
Signature
Date
INSPEKSI Pre-
Pouring Concrete

Service No. Primary Crusher 1A Inspection No. STG-QAS-ISP-045-008
Accepted
Yes No
3 Ties at Rebar
4 Overlap Splaccing

14 Koordinat
16 Form Oil Usage
17 Cleanliness
Note :

Print Name
Signature
Date
INSPEKSI Pre-
Pouring Concrete

Accepted
Yes No
3 Ties at Rebar
4 Overlap Splaccing

14 Koordinat
16 Form Oil Usage
17 Cleanliness
Note :

Print Name
Signature
Date
INSPEKSI Pre-
Pouring Concrete

Accepted
Yes No
3 Ties at Rebar
4 Overlap Splaccing

14 Koordinat
16 Form Oil Usage
17 Cleanliness
Note :

Print Name
Signature
Date
INSPEKSI Pre-
Pouring Concrete

Accepted
Yes No
3 Ties at Rebar
4 Overlap Splaccing

14 Koordinat
16 Form Oil Usage
17 Cleanliness
Note :

Print Name
Signature
Date
INSPEKSI Pre-
Pouring Concrete

Accepted
Yes No
3 Ties at Rebar
4 Overlap Splaccing

14 Koordinat
16 Form Oil Usage
17 Cleanliness
Note :

Print Name
Signature
Date
INSPEKSI Pre-
Pouring Concrete

Accepted
Yes No
3 Ties at Rebar
4 Overlap Splaccing

14 Koordinat
16 Form Oil Usage
17 Cleanliness
Note :

Print Name
Signature
Date

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REQUEST FOR INSPECTION (RFI)

Doc No. : WRK-QAS-RFI-SRG-090-

Date & Time

Sub Item / Reference Date / Time of Inspection

Acceptable, you may proceed WITH/WITHOUT our attendance.

Please reschedule the witness/inspection date

Name / Signature of PT.DSP : Date / Time :

Name / Signature of PT.WRK : Date / Time :

Name / Signature of Subcont / Vendor : Date / Time :

PT. KODECO ARGOJAYA MANDIRI PT. WIJAYA KARYA REKAYASA KONSTRUKSI

PT. DUA SAMUDERA PERKASA PT. WIJAYA KARYA REKAYASA KONSTRUKSI

DOKUMENTASI PRE - POURING STG-QAS-ISP-045-056

Subject Inspeksi Pre-Pouring Concrete Date

2 Diameter & distance of Stirrup

5 Concrete Cover / Conrete decking

8 Material quality (shape & surface)

9 Dimension ( Widht, length, height)

10 Shoring & support

11 Tiltness of the vertical tolerance

12 Straightness of line of the formwork

13 Elevation (Top Cor)

16 Form Oil Usage

PT. WIKA REKAYASA KONSTRUKSI PT. DUA SAMUDERA PERKASA

Subject Inspeksi Pre-Pouring Concrete Date 07 Agustus 2022

2 Diameter & distance of Stirrup

5 Concrete Cover / Conrete decking

8 Material quality (shape & surface)

9 Dimension ( Widht, length, height)

10 Shoring & support

11 Tiltness of the vertical tolerance

12 Straightness of line of the formwork

13 Elevation (Top Cor)

16 Form Oil Usage

PT. WIKA REKAYASA KONSTRUKSI PT. DUA SAMUDERA PERKASA

Subject Inspeksi Pre-Pouring Concrete Date 11 Agustus 2022

2 Diameter & distance of Stirrup

5 Concrete Cover / Conrete decking

8 Material quality (shape & surface)

9 Dimension ( Widht, length, height)

10 Shoring & support

11 Tiltness of the vertical tolerance

12 Straightness of line of the formwork

13 Elevation (Top Cor)

16 Form Oil Usage

PT. WIKA REKAYASA KONSTRUKSI PT. DUA SAMUDERA PERKASA

Subject Inspeksi Pre-Pouring Concrete Date 11 Agustus 2022

2 Diameter & distance of Stirrup

5 Concrete Cover / Conrete decking

8 Material quality (shape & surface)

9 Dimension ( Widht, length, height)

10 Shoring & support

11 Tiltness of the vertical tolerance

12 Straightness of line of the formwork

13 Elevation (Top Cor)

16 Form Oil Usage

PT. WIKA REKAYASA KONSTRUKSI PT. DUA SAMUDERA PERKASA

Subject Inspeksi Pre-Pouring Concrete Date 15 Agustus 2022

2 Diameter & distance of Stirrup

5 Concrete Cover / Conrete decking

8 Material quality (shape & surface)