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LAMPIRAN III

Standard Formulir Aktivitas Kapal


di Pelabuhan


1. Compartment Log Sheet
2. Delivery Certificate
3. Disch Agreement
4. Dry After Disch Certificate
5. Dry Before Loading Certificate
6. Inspection Record
7. Letter of Discrepancy
8. Letter of Protest Pumping Rate
9. Loading Agreement
10. Log Abstract
11. Master Cable
12. Master Requisition
13. Notice of Readiness
14. Notice of Sealing
15. Off Hire Certificate
16. On Hire Certificate
17. Oil Spill
18. Pumping Log
19. Redelivery Certificate
20. ROB Bunker
21. Sailing Order
22. Ship Condition
23. Statement of fact
24. Statement of Reduce rate
25. Stop Temporary
26. Tanker Time Sheet
27. Ullage Report





PT PERTAMINA (PERSERO)
SHIPPING MARKETING & TRADING DIRECTORATE
SHIPPING OPERATION DIVISION, HEAD OFFICE 19
TH
Floor, Jln. Merdeka Timur 1A Jakarta 10110
Phone : (62-21) 3816367, 3816314, 3816339, 3816353, 3816217. Fax : 3455430, 3816348, 3507121
E-mail: opstanker@pertaminashipping.com

COMPARTMENT LOGSHEET
AFTER/BEFORE/LOADING/DISCHARGING

VESSELS NAME : DRAFT (Mtr) F M A
PORT / DATE : BEFORE LOAD / DISCH :
VOYAGE : AFTER LOAD / DISCH :


LOADING MASTER PT. PERTAMINA (PERSERO) CHIEF OFFICER
Shipping Representative/Agent


CARGO
TANKS
NO
TANK OBSERVATION SAMPLES OBS
DENSITY
@ 15C
(TABLE 53)
VOL COR
FACTOR
(TABLE 54)
NET KL
@ 15C
VOLUME
CONV
FACTOR
(TABLE 52)
BARRELS
@60F
WEIGHT
CONV
FACTOR
(TABLE 57)
LONG
TONS
METRIC
TONS GRADE
CORR
ULL
GROSS
VOL (KL)
FREE WATER NET
VOL
(KL)
DENS
TEMP
(
o
C ) DIP
VOL
(KL)
(1) (2) (3) (4) (5) (6) (7) (8) (9) (10) (11) (12) (13) (14) (15) (16) (17)
PORT
1
2
3
4
5
6
7
8
CENTER
1
2
3
4
5
6
7
8
STBD
1
2
3
4
5
6
7
8
TOTAL





PT PERTAMINA (PERSERO)
SHIPPING MARKETING & TRADING DIRECTORATE
SHIPPING OPERATION DIVISION, HEAD OFFICE 19
TH
Floor, Jln. Merdeka Timur 1A Jakarta 10110
Phone : (62-21) 3816367, 3816314, 3816339, 3816353, 3816217. Fax : 3455430, 3816348, 3507121
E-mail: opstanker@pertaminashipping.com

DELIVERY CERTIFICATE




It was also agreed at that time that the vessel had onboard bunker and fresh
water as
water as follows :


Marine Fuel Oil : Metric Ton.
Marine Diesel Oil : Metric Ton.
Autogas (HSD) : Metric Ton.
Fresh Water : Ton.

Port

Port
:
:
Date
:
:


PT PERTAMINA (PERSERO) Master MT / SS / TB
Representative

(For and on behalf of Charterer) (For and on behalf of Owner)





This is to certify that MT / SS / TB : Call Sign
:

Flag : Gross Tons : was duly delivered
by the Master (for and on behalf of Owner), to and accepted by
PT PERTAMINA (PERSERO)
(for and on behalf of Charterer), at
hours local time, on
Name of Ship Disch. Port
Voy No. F : . . . . . . . . .
Date Loading Port M : . . . . . . . . .
Berth/Jetty A : . . . . . . . . .
:
:
:
:
Load/Disch. Rate / Pressure at Manifold as Agreement : . . . . . . . . . . . . .KL/hrs - . . . . . . . . . . .kg/cm
2
Remark :
Note :
Line : Pipa (muat / bongkar) SFBD : Ship's Figure Beofore Discharge F : Forward (depan)
LA : Loading Arm (pipa muat) Voy No.: Voyage No. (No. Pelayaran) M : Mid (tengah)
COP : Cargo Oil Pump (pompa utama) KL Obs : Kilo Liter Observasi (pengamatan) A : After (belakang)
Line : Diameter pipa dalam inchi Shore : Darat Hrs : Jam
Grade : Jenis Muatan
Berth/Jetty : Nama tempat sandar (dermaga/SBM)
- Kegiatan bongkar harus direcord dalam pumping log dan ditandatangani pihak kapal dan pihak darat.
-
Line= inchi
Grade
1.
Estimated Completed Load/Disch. time
(including stripping)
:
3.
. . . . . . . . . . . . . . . . . . .hrs
RECEIVING AVAILABILITY AND CAPACITY
Shore Ship's
kg/cm2 kg/cm
2
Mtr
PT. PERTAMINA (PERSERO)
DIREKTORAT PEMASARAN DAN NIAGA - PERKAPALAN
LOADING/DISCHARGING AGREEMENT
COP
2.
Quantity Load/Disch
in KL Obs
Line = inchi
. . . . . . . . . . . . . . . . . . . . . . . . .
: . . . . . . . . . . . . . . . . . . . . . . . . . .
: . . . . . . . . . . . . . . . . . . . . . . . . . .
: . . . . . . . . . . . . . . . . . . . . . . . . . .
: . . . . . . . . . . . . . . . . . . . . . . . . . .
Draft
Mtr
. . . . . . . . . . . . . . . . . . . . . .
In the event the discharging rate/pressure at manifold of the vessel is below the agreement mention above
then the vessel will be claim for slow pumping, if the slow pumping is caused by the vessel fault.
Mtr
Loading Master
Pressure
C O P use
Line(LA) use &
Load/Disch. Rate
Penurunan tekanan / rate atas permintaan darat/kapal harus dibuat secara tertulis dan ditandatangani pihak kapal &
darat
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
: . . . . . . . . . . . . . . . . . . . . . .
: . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
KL/hrs KL/hrs
Total Quantity Load/ Discharge =
Master
PT PERTAMINA (PERSERO)
SHIPPING MARKETING & TRADING DIRECTORATE
SHIPPING OPERATION DIVISION, HEAD OFFICE 19
TH
Floor, Jln. Merdeka Timur 1A Jakarta 10110
Phone : (62-21) 3816367, 3816314, 3816339, 3816353, 3816217. Fax : 3455430, 3816348, 3507121
E-mail: opstanker@pertaminashipping.com


DRY CERTIFICATE
(After Discharging)



To:

I, the Loading Master, have inspected all ships tanks
at hours local time, on 20
and found dry & empty.

All cargo on board has been delivered in good order and condition

Remark:
Quantity of ROB :
or OBQ



Yours truly,



Loading Master



To Loading Master,

We confirmed acceptance of your written dry certificate at
hours local time, on


Yours truly,




Master
PORT:
DATE: 20


PT PERTAMINA (PERSERO)
SHIPPING MARKETING & TRADING DIRECTORATE
SHIPPING OPERATION DIVISION, HEAD OFFICE 19
TH
Floor, Jln. Merdeka Timur 1A Jakarta 10110
Phone : (62-21) 3816367, 3816314, 3816339, 3816353, 3816217. Fax : 3455430, 3816348, 3507121
E-mail: opstanker@pertaminashipping.com


DRY CERTIFICATE
(Before Loading)



To:

I, the Master of , have inspected all ships tanks
at hours local time, on 20
and found dry & clear.

And ready to commence loading of the cargo

Remark:
Quantity of ROB :
or OBQ :



Yours truly,



Master

To Master of MT,

We confirmed acceptance of your written dry certificate at
hours local time On

Yours truly,




Loading Master



PORT:
DATE: 20


PT PERTAMINA (PERSERO)
SHIPPING MARKETING & TRADING DIRECTORATE
SHIPPING OPERATION DIVISION, HEAD OFFICE 19
TH
Floor, Jln. Merdeka Timur 1A Jakarta 10110
Phone : (62-21) 3816367, 3816314, 3816339, 3816353, 3816217. Fax : 3455430, 3816348, 3507121
E-mail: opstanker@pertaminashipping.com


INSPECTION RECORD





































SHIPS COMP.
BOTTOM WALL VALVE HEATING COILS HEATING COILS
Empty
Free
Water
Clean D/S/WP Clean D/S/WP O/C Sealed
Sealed
Number
D/S Leak Empty Content
(1) (2) (3) (4) (5) (6) (7) (8) (9) (10) (11) (12) (13) (14)
PORT 1
2
3
4
5
6
7
8
CENTER 1
2
3
4
5
6
7
8
STBD 1
2
3
4
5
6
7
8
Cofferdam
Slop Tank
Fore Peak Tank
After Peak Tank



Notes: Oil Inspector for Cleanliness : P&T Agent Oil Inspector/ Loading Master Mualim I / Chief Officer
Loading Master
: for Cargo
Discharging Master
Discharging Master
PT PERTAMINA (PERSERO)
SHIPPING MARKETING & TRADING DIRECTORATE
SHIPPING OPERATION DIVISION, HEAD OFFICE 19
TH
Floor, Jln. Merdeka Timur 1A Jakarta 10110
Phone : (62-21) 3816367, 3816314, 3816339, 3816353, 3816217. Fax : 3455430, 3816348, 3507121
E-mail: opstanker@pertaminashipping.com

SURAT PERBEDAAN ANGKA MUATAN
LETTER OF DISCREPANCY

Tanggal
:
Date
Voyage :
Pelabuhan
:
Port


Kepada
:
To
Dari Nakhoda
:
From Master

Setelah pengecekan kembali dengan teliti figures
muatan yang dimuat serta disesuaikan dengan draft
dan deadweight dari kapal kami, maka terdapat
perbedaan lebih dari setengah () persen antara B/L
figures dengan ships figures dengan perincian
sebagai berikut :
After having been rechecked the figures of the
cargo loaded carefully and compared it with the
draft and deadweight of our vessel, a difference
of more than half () percent between B/L and
the ships figures has been found as follows :

Jenis

Angka Kapal

No. dan angka B/L Selisih
Grade Ship Figures No. and B/L figures Difference



Bbls Bbls %
Bbls Bbls %
Bbls Bbls %

Berdasarkan figures tersebut diatas dengan ini kami
menyatakan bahwa B/L telah kami tandatangani
dibawah protes dengan ketentuan bahwa kapal
tidak dapat dipertanggung jawabkan atas figures
pembongkaran pada pelabuhan bongkar.
Catatan :
Tanker Ullage Report pertama dan kedua diukur
dan dihitung bersama-sama Loading Master serta
Agen dan telah diserahkan ke perwakilan/Agen
PT. PERTAMINA (PERSERO).
Base on above mentioned figures, we here by
declare that the B/L has been signed under
protest, notably that the ship could not be hold
responsible for the outturn figures at the
discharging port.
Remarks :
The first and the second Tanker Ullage Report
already measure and calculated together with
Loading Master and Agent and send to
PT. PERTAMINA (PERSERO) Representative.

Hormat kami
Diketahui
Yours faithfully Known by

Nakhoda
PT PERTAMINA (PERSERO)
Representative

Master






PT PERTAMINA (PERSERO)
SHIPPING MARKETING & TRADING DIRECTORATE
SHIPPING OPERATION DIVISION, HEAD OFFICE 19
TH
Floor, Jln. Merdeka Timur 1A Jakarta 10110
Phone : (62-21) 3816367, 3816314, 3816339, 3816353, 3816217. Fax : 3455430, 3816348, 3507121
E-mail: opstanker@pertaminashipping.com



LETTER OF PROTEST
Slow Pumping

DATE :

PORT :

BERTH :


To :


As recorded, that my vessel is capable to loading / discharging cargo at
TONS/BBLS/M
3
per hour with
line inches connection. However, shore can only supply /receive of
TONS/BBLS/M
3
per hour
line. Equivalent to hours actual loading /discharging time.

In view of the foregoing, I Master of MT protest the delay of
loading / discharging and on behalf of my Owners and Consignee / Charterer reserves
their right to claim you for all time losses and expenses incured, if any, and that such
claims to forthcome at an appropriate time and place my principal deemed it.






Loading Master Master / Duty Officer



Port of :
Date :

PT PERTAMINA (PERSERO)
SHIPPING MARKETING & TRADING DIRECTORATE
SHIPPING OPERATION DIVISION, HEAD OFFICE 19
TH
Floor, Jln. Merdeka Timur 1A Jakarta 10110
Phone : (62-21) 3816367, 3816314, 3816339, 3816353, 3816217. Fax : 3455430, 3816348, 3507121
E-mail: opstanker@pertaminashipping.com

LOG ABSTRACT
(The voyage should cover the period End of Sea Voyage as per Log at first Loading Port until return same position Next Loading Port, after discharging all cargo)

VESSEL NAME : VOYAGE NO :

PORT TIME : (Loading / Discharging)
Port
End of Sea Voyage Begin Of Sea Voyage Port Time
(Hours)
Cargo Load / Disch. (Long Ton)
Activity Date Time

Description Hours
Fuel & FW Counsumption (MT)
Date Time Date Time B / L SFAL/SFBD Grade MFO MDO HSD FW
St. by. Eng. (EOSV) Steaming in/out
FWE Idle
St. by. Eng. Load/ Disch
FWE Ballast/ Deballast
Remark : Comm. Load/Disc. Cargo Heating
Complt. Load/Disc. IGS
St. by. Eng. Total
FWE
St. by. Eng. ROB ATA
Full Away (BOSV) ROB ATD
REPLENISHMENT
SEA PASSAGE : (Laden / Ballast)
From
(BOSV)
To
(EOSV)
Distance
(Miles)
Steaming
Time (Hours)
Av. Speed
(Knots)
Fuel & FW Consumption (MT) Description Hours
MFO MDO HSD FW Heat
Port: Port: Tk. Clean
Date: Time: Date: Time: IGS

PORT TIME : (Loading / Discharging)
Port
End of Sea Voyage Begin Of Sea Voyage Port Time
(Hours)
Cargo Load / Disch. (Long Ton)
Activity Date Time

Description Hours
Fuel & FW Counsumption (MT)
Date Time Date Time B / L SFAL/SFBD Grade MFO MDO HSD FW
St. by. Eng. (EOSV) Steaming in/out
FWE Idle
St. by. Eng. Load/ Disch
FWE Ballast/ Deballast
Remark : Comm. Load/Disc. Cargo Heating
Complt. Load/Disc. IGS
St. by. Eng. Total
FWE
St. by. Eng. ROB ATA
Full Away (BOSV) ROB ATD
REPLENISHMENT
SEA PASSAGE : (Laden / Ballast)
From
(BOSV)
To
(EOSV)
Distance
(Miles)
Steaming
Time (Hours)
Av. Speed
(Knots)
Fuel & FW Consumption (MT) Description Hours
MFO MDO HSD FW Heat
Port: Port: Tk. Clean
Date: Time: Date: Time: IGS

State exast periods of delay caused by accident engine trouble crew heavy weather and the like :


Deviation to storing and / or repair port :
Master :
Distance to go at time of deviation to next loading / discharging port : Miles.
Place / Point of Deviation Date / Hour
Returned to point of deviation or corresponding position Date / Hour
Actual periode of deviation : Days Hour Chief Engineer :
Bunker and F.W. consumed during the deviation periode FO : DO : HSD : FW :


PT PERTAMINA (PERSERO)
SHIPPING MARKETING & TRADING DIRECTORATE
SHIPPING OPERATION DIVISION, HEAD OFFICE 19
TH
Floor, Jln. Merdeka Timur 1A Jakarta 10110
Phone : (62-21) 3816367, 3816314, 3816339, 3816353, 3816217. Fax : 3455430, 3816348, 3507121
E-mail: opstanker@pertaminashipping.com

RE : DEPARTURE MASTER CABLE

ROC. 1863 / OT II DATED 18 / 08 / 1999 AS TO GET A COMPLETE DEPARTURE
MESSAGE. YOU ARE REQUESTED TO ADVISE ALL DETAILS BELOW AT THE FIRST
PRIORITY FOR EACH ACTIVITY:

AA.
BB.
CC.
DD.
EE.
FF.
GG.
DD.
EE.
FF.
GG.
HH.
II.
JJ.
KK.
LL.
MM.
NN.
OO.
PP.
QQ.
RR.
SS.
TT.
UU.
VV.
WW.
XX.
YY.


THANKS FOR YOUR ATTENTION COOPERATION ACK REGARDS.


PT PERTAMINA (PERSERO)
SHIPPING MARKETING & TRADING DIRECTORATE
SHIPPING OPERATION DIVISION, HEAD OFFICE 19
TH
Floor, Jln. Merdeka Timur 1A Jakarta 10110
Phone : (62-21) 3816367, 3816314, 3816339, 3816353, 3816217. Fax : 3455430, 3816348, 3507121
E-mail: opstanker@pertaminashipping.com


MASTERS REQUISITION



Port :
Date :


Dear Sir :
Please supply my vessel the as / my : With,
MARINE FUEL OIL KL / MT
Maximum viscosity redwood 1 @ 100 o F Seconds
Rate per hour for delivery
MARINE DIESEL FUEL KL / MT
Rate per hour for delivery
GAS OIL KL / MT
Rate per hour for delivery
DRINGKING WATER Tons
BOILER WATER Tons
And charge same to my Principals namely :



I require the grades to be supplied in the following order :
And * will / * will not appoint a representative to withness and check either the opening and closing meter
readings/ calculations or if meters no available, the opening and closing tank dips/calculations only
behalf.
The ship / * there will give the final stop pumping signal.

Your very truly
Master MT :
( )

PT PERTAMINA (PERSERO)
SHIPPING MARKETING & TRADING DIRECTORATE
SHIPPING OPERATION DIVISION, HEAD OFFICE 19
TH
Floor, Jln. Merdeka Timur 1A Jakarta 10110
Phone : (62-21) 3816367, 3816314, 3816339, 3816353, 3816217. Fax : 3455430, 3816348, 3507121
E-mail: opstanker@pertaminashipping.com


NOTICE OF READINESS
Voy. No.


PORT :
DATE :
TIME TENDERED :

To:
Dear Sir,
I hereby tender you the MT
at the date time shown above as being ready in all respect to commence the
loading/ discharging of her cargo
consisting of:

Description of cargo Approximate amount/Bill of Lading quantity




Laytime will commence as specified in the charter party covering this voyage



ACCEPTED Very truly yours

Date : Hour:



By :
as Agent Master






PT PERTAMINA (PERSERO)
SHIPPING MARKETING & TRADING DIRECTORATE
SHIPPING OPERATION DIVISION, HEAD OFFICE 19
TH
Floor, Jln. Merdeka Timur 1A Jakarta 10110
Phone : (62-21) 3816367, 3816314, 3816339, 3816353, 3816217. Fax : 3455430, 3816348, 3507121
E-mail: opstanker@pertaminashipping.com



NOTICE OF SEALING
No :


After completing : cargo
Loaded in tank :


Of the MV / MT :
On the :

The following valves and tanklide were sealed by Loading

Number and name valves/tanklide sealed :
: pcs
: pcs
: pcs
: pcs
: pcs
: pcs
: pcs
: pcs
: pcs
: pcs
: pcs
Total : pcs



20
Scaling Acknowledge by : Signature




Chief Engineer Loading Master


Cc : Consignee
Chief Officer
Pelsus
Inst. Tank
PT PERTAMINA (PERSERO)
SHIPPING MARKETING & TRADING DIRECTORATE
SHIPPING OPERATION DIVISION, HEAD OFFICE 11
TH
Floor, Jln. Merdeka Timur 1A Jakarta 10110
Phone : (62-21) 3816367, 3816314, 3816339, 3816353, 3816217. Fax : 3455430, 3816348, 3507121
E-mail: opstanker@pertaminashipping.com


OFF HIRE CERTIFICATE

This is to certify that MT / SS / TB :
Call Sign: Flag :
DWT : was duly off hire by PT PERTAMINA (PERSERO)

(for and on behalf of Charterer), to and accepted by Master (for and on behalf of
owner), at hours local time, on

It was also agreed at that time that the vessel had onboard bunker and fresh water
as follows :

Marine Fuel Oil (180cst/380cst)* : Metric Ton.
Marine Diesel Oil : Metric Ton.
Autogas (HSD) : Metric Ton.
Marine Gas Oil (MGO) : Metric Ton.
Fresh Water : Ton.
*)coret yang tidak perlu

Port :
Date :


Master MT / SS / TB PT PERTAMINA (PERSERO)
Representative

(For and on behalf of Owner) (For and on behalf of Charterer)





PT PERTAMINA (PERSERO)
SHIPPING MARKETING & TRADING DIRECTORATE
SHIPPING OPERATION DIVISION, HEAD OFFICE 19
TH
Floor, Jln. Merdeka Timur 1A Jakarta 10110
Phone : (62-21) 3816367, 3816314, 3816339, 3816353, 3816217. Fax : 3455430, 3816348, 3507121
E-mail: opstanker@pertaminashipping.com



LAPORAN PEMERIKSAAN PENCEGAHAN TUMPAHAN MINYAK DI PERAIRAN

1. Kapal Terminal
2. Pemilik Kapal
3. Dioperasikan oleh
4. Agen Nama Alamat
5. Nama Nakhoda
6. Tiba di Tgl jam
Di dermaga Tgl jam
7. Berlabuh jangkar dari jam Tgl sampai jam Tgl
8. Jenis muatan
9. Apakah Oil Boom dipasang
10. Apakah kerangan-kerangan pipa pembuangan air ballast kotor / air got ke laut tertutup rapat sebelum
penyegelan
11. Apakah semua penutup lubang untuk mengukur minyak di tangki muatan (ullage cover screens) ada pada
tempatnya sebelum pemompaan dimulai
12. Jumlah segel yang digunakan
13. Jumlah dispersant yang ada di kapal
Jenis Merk Pabrik
14. Tanda tangan Perwira dan Pemeriksa Darat yang melaksanakan penyegelan :
( ) ( )
Perwira Kapal Pemeriksa Darat
15. Apakah saluran pembuangan air dek
kapal sudah disumbat sebelum
pompa dihidupkan
Apakah talang penadah tumpahan
minyak berada dibawah manifold
kapal
Apakah talang penadah tumpahan
minyak untuk kapal tersedia di darat.


16. Slang terakhir telah terpasang jam tgl 20
Pembongkaran/pemuatan dimulai jam tgl 20
17. Selesai pembongkaran/pemuatan jam tgl 20
Slang terakhir dilepas jam tgl 20
Apakah ujung slang terakhir telah tertutup rapat waktu dimulainya pemompaan ballast diatas kapal
sebelum diturunkan ke darat jam tgl 20
Waktu segel dibuka untuk pengisian air ballast apakah segel-segel masih utuh sebelum dibuka
jam tgl 20
18. Tanda tangan Perwira Kapal dan Pemeriksa Darat waktu membuka segel :
( ) ( ( )
Perwira Kapal Pemeriksa Darat
19. Apakah saluran pembuangan air
dek kapal sudah disumbat
sebelum pompa dihidupkan
Apakah talang penadah tumpahan
minyak berada dibawah manifold kapal
Apakah talang penadah tumpahan
minyak untuk kapal tersedia di darat.


20. Bilamana ada minyak terlihat diatas air disekitar kapalberikan laporan terperinci dibawah ini :






21. Data Kapal :
- DWT :
- GRT :
- LOA :
- FLAG :


PT PERTAMINA (PERSERO)
SHIPPING MARKETING & TRADING DIRECTORATE
SHIPPING OPERATION DIVISION, HEAD OFFICE 19
TH
Floor, Jln. Merdeka Timur 1A Jakarta 10110
Phone : (62-21) 3816367, 3816314, 3816339, 3816353, 3816217. Fax : 3455430, 3816348, 3507121
E-mail: opstanker@pertaminashipping.com


ON HIRE CERTIFICATE

This is to certify that MT / SS/ TB :
Call Sign: Flag :
DWT : was duly on hire by the Master
(for and on behalf of Owner) to and accepted by PT PERTAMINA (PERSERO)
(for and on behalf of Charterer),
at hours local time, on

It was also agreed at that time that the vessel had onboard bunker and fresh water
as follows :

Marine Fuel Oil (180cst/380cst)* : Metric Ton.
Marine Diesel Oil : Metric Ton.
Autogas (HSD) : Metric Ton.
Marine Gas Oil (MGO) : Metric Ton.
Fresh Water : Ton.
*)coret yang tidak perlu




PT PERTAMINA (PERSERO) Master MT / SS / TB
Representative

(For and on behalf of Charterer) (For and on behalf of Owner)








Port :
Date :

PT PERTAMINA (PERSERO)
SHIPPING MARKETING & TRADING DIRECTORATE
SHIPPING OPERATION DIVISION, HEAD OFFICE 19
TH
Floor, Jln. Merdeka Timur 1A Jakarta 10110
Phone : (62-21) 3816367, 3816314, 3816339, 3816353, 3816217. Fax : 3455430, 3816348, 3507121
E-mail: opstanker@pertaminashipping.com


ON HIRE CERTIFICATE

This is to certify that MT / TT/ TB :
Call Sign: Flag :
DWT : was duly on hire by the Master
(for and on behalf of Owner) to and accepted by PT PERTAMINA (PERSERO)
(for and on behalf of Charterer),
at hours local time, on

It was also agreed at that time that the vessel had onboard bunker and fresh water
as follows :

Marine Fuel Oil : Metric Ton.
Marine Diesel Oil : Metric Ton.
Autogas (HSD) : Metric Ton.
Fresh Water : Ton.





PT PERTAMINA (PERSERO) Master MT / TT / TB
Representative

(For and on behalf of Charterer) (For and on behalf of Owner)








Port :
Date :
MT PRESS ALLOW BY SHORE ON HOSE : kg/m
2
PORT OF DATE AVERAGE PRESS MAINTAINED SHIP RAIL : kg/m
2
NO OF PUMP NORMAL SERV. RPM NO OF HOSE : SIZE : inches
SHORE LINES NO : SIZE : inches
RPM
PRESS
AT RAIL
(kg/cm
2
)
PUMPING
RATE
(m
3
/h)
RPM
PRESS
AT RAIL
(kg/cm
2
)
PUMPING
RATE
(m
3
/h)
RPM
PRESS
AT RAIL
(kg/cm
2
)
PUMPING
RATE
(m
3
/h)
RPM
PRESS
AT RAIL
(kg/cm
2
)
PUMPING
RATE
(m
3
/h)
NO
SG/
DENSITY
1 DATE HOUR MINUTE DATE HOUR MINUTE
2
3
4
5
6
7
PRESSURE RECORDED SHIP' RAIL / UPPER PUMP ROOM / LOWER PUMP ROOM :
IF ANY PUMP WAS NOT IN OPERATION ADVISE REASON :
IF DISCHARGEING INTERUPTED ADVISE REASON :
IF NORMAL RPM WERE NOT MAINTAINED ADVISE REASON :
IF ANY DELAY INCURRED DUE TO SHORE ORDER ATTACH WRITTEN INSTRUCTION :
PT PERTAMINA (PERSERO) CHIEF OFFICER MASTER
Representative
DATE HOURS
MAIN PUMP NO.3 MAIN PUMP NO.1 MAIN PUMP NO.2
REMARKS
MAIN PUMP NO.4
: :
PT PERTAMINA (PERSERO)
SHIPPING OPERATION DIVISION, PT PERTAMINA (PERSERO) HEAD OFFICE 11
TH
Floor, Jln. Merdeka Timur 1A Jakarta 10110
Phone : (62-21) 3816367, 3816314, 3816369, 3816353, 3816217. Fax : 3455430, 3816348, 3507121
E-mail: opstanker@pertaminashipping.com
CARGO GRADE AND
QUANTITY
TEMP OBSERVED
(oC)
PUMPING / DISCHARGE LOG
SHIPPING - MARKETING & TRADING DIRECTORATE
:
: :
COMMENCED DISCHARGE COMPLETED DISCHARGE
DISCH.
TIME
STOP DISCHARGE TOTAL
STOP
REASON
FROM TO

PT PERTAMINA (PERSERO)
SHIPPING MARKETING & TRADING DIRECTORATE
SHIPPING OPERATION DIVISION, HEAD OFFICE 11
TH
Floor, Jln. Merdeka Timur 1A Jakarta 10110
Phone : (62-21) 3816367, 3816314, 3816339, 3816353, 3816217. Fax : 3455430, 3816348, 3507121
E-mail: opstanker@pertaminashipping.com



REDELIVERY CERTIFICATE

This is to certify that MT / SS / TB : Call Sign :
Flag : DWT : was duly redelivered by
PT PERTAMINA (PERSERO)
(for and on behalf of Charterer), to and accepted by Master (for and on behalf
of
Owner), at hours local time, on

It was also agreed at that time that the vessel had onboard bunker and fresh
water as follows :

Marine Fuel Oil (180cst/380cst)* : Metric Ton.
Marine Diesel Oil : Metric Ton.
Autogas (HSD) : Metric Ton.
Marine Gas Oil (MGO) : Metric Ton.
Fresh Water : Ton.
*) coret yang tidak perlu


Port :
Date :

Master MT / SS / TB PT PERTAMINA (PERSERO)
Representative

(For and on behalf of Owner) (For and on behalf of Charterer)








PT PERTAMINA (PERSERO)
SHIPPING MARKETING & TRADING DIRECTORATE
SHIPPING OPERATION DIVISION, HEAD OFFICE 11
TH
Floor, Jln. Merdeka Timur 1A Jakarta 10110
Phone : (62-21) 3816367, 3816314, 3816339, 3816353, 3816217. Fax : 3455430, 3816348, 3507121
E-mail: opstanker@pertaminashipping.com


Note : Average for SG MFO = 0.921 ; MDO = 0.856 ; HSD = 0.838
(ref. kpts no.074/C0000/96B1 dated April 22, 1996)



BUNKER REMAIN ON BOARD
ATA / ATD

VESSELS NAME :
VOYAGE :
DATE :
PORT :
DRAFT
F : Mtr
M : Mtr
A : Mtr

MFO / IFO TANKS :

NO TANK
ULLAGE /
SOUNDING
VOLUME
(KL / M3 )
TEMP
(
o
C)
SG
TANKS
VCF
METRIC
TON














TOTAL

MDO / HSD / MGO TANKS :

NO TANK
ULLAGE /
SOUNDING
VOLUME
(KL / M3 )
TEMP
(
o
C)
SG
TANKS
VCF
METRIC
TON






TOTAL

All bunker tanks has been inspected and calculated together between :

PT. PERTAMINA (PERSERO) Chief Engineer :
Representative





PT PERTAMINA (PERSERO)
SHIPPING MARKETING & TRADING DIRECTORATE
SHIPPING OPERATION DIVISION, HEAD OFFICE 19
TH
Floor, Jln. Merdeka Timur 1A Jakarta 10110
Phone : (62-21) 3816367, 3816314, 3816339, 3816353, 3816217. Fax : 3455430, 3816348, 3507121
E-mail: opstanker@pertaminashipping.com



SAILING ORDER



To : Master MT/TT/TB Date :
No :

Dear sir,
Please proceed to

on

after completion
of Loading/Discharging at

, for Loading/Discharging as follows :

Cargo : Quantities : Destination









The complete information about next port will sent via telex if necessary.
Please follow the instruction from Tanker Operation.


Yours truly
PT PERTAMINA (PERSER0)
Representative




PT PERTAMINA (PERSERO)
SHIPPING MARKETING & TRADING DIRECTORATE
SHIPPING OPERATION DIVISION, HEAD OFFICE 19
TH
Floor, Jln. Merdeka Timur 1A Jakarta 10110
Phone : (62-21) 3816367, 3816314, 3816339, 3816353, 3816217. Fax : 3455430, 3816348, 3507121
E-mail: opstanker@pertaminashipping.com


SHIP CONDITION
MT




Master / Chief Officer



( .. )
LAST PORT CONDITION FROM :

ARRIVAL :

REPLENISHMENT DEPARTURE TO:

DATE :

DATE : DATE : DATE :
TIME :

TIME : TIME : TIME :
BUNKER BUNKER BUNKER BUNKER
MFO :

MT MFO : MT MFO : MT MFO : MT
MDO : MT MDO : MT MDO : MT MDO : MT
HSD : MT HSD : MT HSD : MT HSD : MT
FRESH WATER FRESH WATER FRESH WATER FRESH WATER
BW : Tons BW : Tons BW :

Tons BW : Tons
FW : Tons FW : Tons FW : Tons FW : Tons
DRAFT DRAFT



DRAFT
Fore :

Mtr FORE Mtr Fore : Mtr
After : Mtr AFTER : Mtr After : Mtr
Total
Distance
:

N /Miles

PORT
:
PELABUHAN
DATE :

TANGGAL
PT PERTAMINA (PERSERO)
SHIPPING MARKETING & TRADING DIRECTORATE
SHIPPING OPERATION DIVISION, HEAD OFFICE 11
TH
Floor, Jln. Merdeka Timur 1A Jakarta 10110
Phone : (62-21) 3816367, 3816314, 3816339, 3816353, 3816217. Fax : 3455430, 3816348, 3507121
E-mail: opstanker@pertaminashipping.com


Statement Of Fact
(Ship Unreadiness and Readiness)

To whom it may concern

I the Master of MT/SS/TB. Call sign :
Flag : DWT :
Declare that vessel is not ready on the date : hour :
(hours local time) In the position while

ROB for MFO (180cst/380cst) : MT.
MDO : MT.
HSD : MT.
MGO : MT.
FW : Ton.

Remarks :



Vessel is ready for :
Date : Hour : (hours local time)

ROB for MFO (180cst/380cst) : MT.
MDO : MT.
HSD : MT.
MGO : MT.
FW : Ton.

Remarks :



Port :
Date :
Acknowledge
PT. PERTAMINA (PERSERO)
Representative

Master MT /SS/ TB :






PT PERTAMINA (PERSERO)
SHIPPING MARKETING & TRADING DIRECTORATE
SHIPPING OPERATION DIVISION, HEAD OFFICE 19
TH
Floor, Jln. Merdeka Timur 1A Jakarta 10110
Phone : (62-21) 3816367, 3816314, 3816339, 3816353, 3816217. Fax : 3455430, 3816348, 3507121
E-mail: opstanker@pertaminashipping.com


Statement of Reduce Rate
of Loading / Discharging


To whom it may concern

I, Master MT stated that, today,
date at port
at hours local time, as requested by The Loading Master,
,to temporary reduce discharging/ loading rate of cargo
from M
3
/ sec to M
3
/ sec
from hours local time,
until hours local time.

due to :



Kindly sign and return the copy of this letter of acknowledgement.





Loading Master Master / Duty Officer


.



Port of :
Date :

PT PERTAMINA (PERSERO)
SHIPPING MARKETING & TRADING DIRECTORATE
SHIPPING OPERATION DIVISION, HEAD OFFICE 19
TH
Floor, Jln. Merdeka Timur 1A Jakarta 10110
Phone : (62-21) 3816367, 3816314, 3816339, 3816353, 3816217. Fax : 3455430, 3816348, 3507121
E-mail: opstanker@pertaminashipping.com


Statement of Temporary Stop
for Loading / Discharging



To whom it may concern

I, Master MT stated that,
today , date
In port at hours local time, as requested by
the Loading Master,Mr. ,to temporary stop
discharging/ loading cargo from hours local time,
until hours local time.

due to :



Kindly sign and return the copy of this letter of acknowledgement.





Loading Master Master / Duty Officer


...



Port of :
Date :
PT PERTAMINA (PERSERO)
SHIPPING MARKETING & TRADING DIRECTORATE
SHIPPING OPERATION DIVISION, HEAD OFFICE 19
TH
Floor, Jln. Merdeka Timur 1A Jakarta 10110
Phone : (62-21) 3816367, 3816314, 3816339, 3816353, 3816217. Fax : 3455430, 3816348, 3507121
E-mail: opstanker@pertaminashipping.com


TANKER TIME SHEET




STATEMENT OF ACTIVITY DATE HOUR
TOTAL
REMARKS
PART TIME
Actual Time Arrived
B

Anchor at Outer Bar
Pilot On Board
Anchor Up
A

Anchor at Inner Anchorage
Free Pratique Granted
B

Pilot On Board
Anchor Up
NOR Tendered
NOR Accepted
First Line to Shore
A

All Made Fasted
Cargo Hose Connected C
Commenced Ballast / Deballast
A

Completed Ballast / Deballast
Commenced Load / Disch (1)
A
/
C


Stopped Load / Disch order by Ship / Shore
Resume Load / Disch (2)
Stopped Load / Disch order by Ship / Shore
Resume Load / Disch (3)
Completed Load / Disch
Reduced Load / Disch rate order by Ship / Shore
Continues to Agreement Rate Load/ Disch (1)
Reduced Load / Disch rate order by Ship / Shore
Continues to Agreement Rate Load/ Disch (2)
Reduced Load / Disch rate order by Ship / Shore
Continues to Agreement Rate Load/ Disch (3)
Cargo Hose Disconnected C
Ships Paper & Cargo Document on Board B ROB Bunker (Metric Ton)
Commenced Bunker
A
Grade Arrv. Repl. Dept.
Completed Bunker MFO
Cast Off
A
MDO
Anchor at Inner Anchorage HSD
Pilot On Board B FW
Anchor Up
A
LO
Actual Time Departure / Sailed
SHORE FIGURE (BL / AR) SHIP FIGURE (AL / BD)
GRADE
KL Obs
KL 15C
Bbls 60F
LT
MT
TOTAL TIME FOR : SHIP (A) : AGENT (B) : SHORE (C) : PORT TIME HRS
Explanation of Delay : LAYTIME USED HRS
From : To : : LAYTIME ALLOWED HRS
From : To : : EXCESS TIME HRS
From : To : :
Vessel Name : Port of : Next Port :
Flag : Date : ETA :
Master : Voy No. : Draft on Fwd Mean Aft
GRT : Last Port : Arrival : Mtr
DWT : B/L No. : Departure : Mtr
PT PERTAMINA (PERSERO) MT/ TT
Representative MASTER







PT PERTAMINA (PERSERO)
SHIPPING MARKETING & TRADING DIRECTORATE
SHIPPING OPERATION DIVISION, HEAD OFFICE 19
TH
Floor, Jln. Merdeka Timur 1A Jakarta 10110
Phone : (62-21) 3816367, 3816314, 3816339, 3816353, 3816217. Fax : 3455430, 3816348, 3507121
E-mail: opstanker@pertaminashipping.com



ULLAGE / SOUNDING - REPORT

M / T
:
VOYAGE
:
DATE
:
PORT
:
DRAFT
F
: Mtr
M
: Mtr
A
: Mtr


TANK NO
ULLAGES /
SOUND
*

(CM)

OBSERVED
TEMP
CARGO (
o
C)
GRADE REMARKS
TEMP(
o
C)
DENSITY 15
o
C
PORT
1

2
3
4
5
6
7
CENTER
1
2
3
4
5
6
7
STBS
1
2
3
4
5
6
7

Note: If any compartement used for ballast tank or empty, must be explained in the remarks column


.
CHIEF OFFICER
choose one of two