INSPECTION AND TEST PLAN FOR CIVIL WORK

Project : EPCC Pengembangan & Modernisasi PG Assemmbagoes Situbondo M : Monitor P : Provide V : Verify Doc. No. : PGAB-QA-ITP-000-001
Location : Situbondo Jawa Timur R : Review W : Witness SW : Spot Wittness Rev : 0
Client : PT.Perkebunan Nusantara XI H : Hold Point

RESPONSIBILITY
METHOD OF LEVEL OF ACCEPTANCE /
No. INSPECTION ACTIVITY/TEST ITEM VERIFYING DOCUMENT CONSURSIUM
INSPECTION REFERENCE SC PCM PJIT
WBM

1.0 SURVEY
A. Location, number, stability and protection of coordinates and Benchmark
Visual & Dimensional IFC Drawing Civil Report M P SW

2.0 SITE PREPARATION

a. Clearing of contaminated soil Visual Engineering Specification Civil Report P SW SW
d. Demolition Visual Engineering Specification Civil Report P SW SW
e. Debris from clearing, grubbing, stripping and demolition operation shall
be remove to disposal areas Visual Engineering Specification Civil Report P SW SW

f. Temporary Drainage Engineering Specification Civil Report P SW R

3.0 EXCAVATION
1 Preparation
a. Set location, based on shop drawing and Benchmark
Dimensional IFC Drawing Civil Report P SW R

b. Demolition or Protection of Existing Facility Visual IFC Drawing Civil Report P R R

c. Investigation of Existing under-ground Facilities Visual IFC Drawing Civil Report P R R
2 Excavation Work
a. Depth and width of excavation Dimensional IFC Drawing Civil Report P SW R
b. Line, Slope and Grades according to approved drawing Visual IFC Drawing Civil Report P R R
c. Protection of Slope, Visual Engineering Specification Civil Report P R R
d Compaction Test after excavation, confirmed Visual Engineering Specification Civil Report P W R
e. Cleaning ``` Engineering Specification Civil Report P R R

4.0 BACKFILL
1 Preparation
 a. cleaning before backfill Visual Engineering Specification Civil Report P SW R
b. back fill material Visual Engineering Specification Civil Report P SW R
2 Placement of fill
a. Cleaning (removal of trash debris, etc.) in soil Visual Engineering Specification Civil Report P SW R
b. Filling around underground pipe and cable (if any) Visual Engineering Specification Civil Report P SW R
c. Final Elevation Dimensional IFC Drawing Civil Report P SW R
3 3 Testing
a. Compaction test by Sand cone test Test Engineering Specification Civil Report P SW R
4 4 Final Visual Inspection Visual IFC Drawing Civil Report P W R

5.0 PILING WORK

1 Preparation
a. Review Welder Qualification Review Engineering Specification Certificate P R R
b. Sequence of piling Review Engineering Specification P R R
c. Method of joint (clear spacing, end preparation, and appearance of Review Engineering Specification P R R
welding, coating, etc.) Civil Report

d. Quality of pile materials Visual Engineering Specification Civil Report M W R

e. Number and size of pile Dimensional IFC Drawing Civil Report M W R
f. PDA test procedure Review Engineering Specification Procedure P R R
2 Piling Work
a. Location of pile Dimensional IFC Drawing Civil Report P SW R
b. Check joint Test Engineering Specification Civil Report P W R
c. Kalendering of top elevation Dimensional IFC Drawing Civil Report P SW R
d. Elevation of pile head cut off Dimensional IFC Drawing Civil Report P SW R
3 Test
a. PDA Test Test Engineering Specification Test Report P W W

6.0 CONCRETE WORK

1 Preparation
a. Cement type, quality, quantity and compliance with applicable standard Test & Review Engineering Specification Mill Certificate & Laboratory P R R
Test
b. Quality and quantity of aggregate (sieve test, etc.) Test Engineering Specification Mill Certificate & Laboratory P SW R
Test
c. Mix Design Review Engineering Specification Civil Report P R R
d. Trial Mix Test Engineering Specification Civil Report P W R
f. Storing condition of cement and aggregate Visual Engineering Specification - P SW R
g. Location and surface condition of joints Visual & Dimensional Engineering Specification Civil Report P SW R
 h. Cleaning prior to concrete placing Visual Engineering Specification Civil Report P SW R
2 Concrete Pouring
a. Workmanship of placing and consolidation (drop height, thickness of Visual Engineering Specification P W R
layer, proper vibration, etc.) Civil Report

b. Concrete finishing and removal of laitance Visual Engineering Specification Civil Report P SW R
3 Post Concrete Pouring
a. Curing (period, method of preventing moisture loss) Visual Engineering Specification Civil Report P SW R
b. Appearance of surface after form removal (honeycomb, crack, etc.) Visual Engineering Specification Punch List Report P SW R

c. Mortar finishing (level, chamber, crack, mortar proportion, etc.) Visual Engineering Specification Punch List Report P SW R

d. Dimensional inspection for completed casting Dimensional IFC Drawing Civil Report P SW R
4 Test
a. Concrete test (slump, compressive strength, etc.) Test Engineering Specification Civil Report P W R

8.0 REINFORCING BAR WORK

1 Preparation
a. Compliance of material with standard Visual & Dimensional Engineering Specification Civil Report P R R
b. Handling and storing Visual Engineering Specification - P SW R
c. Workmanship in cold bending operation Visual Engineering Specification Civil Report P SW R
d. Surface cleaning (to be free from mud, dirt, grease, loose mill, scale, Visual Engineering Specification P SW R
etc.) Civil Report

2 Installation
a. Location, shape, sizes, numbers, cleaning and spacing of bars Visual & Dimensional IFC Drawing / Barbending P SW R
Schedule Civil Report

b. Length and location of lap splice Visual & Dimensional IFC Drawing / Barbending P SW R
Schedule Civil Report

c. Rigidity of rebar assembly to withstand concrete pouring Visual Engineering Specification Civil Report P SW R
d. Strong condition (to prevent corrosion and deformation) Visual Engineering Specification Civil Report P SW R
e. Prohibiting item (welding) Visual Engineering Specification Civil Report P SW R

9.0 FORM WORK

1 Preparation
a. Quality and shape of material Visual Engineering Specification Civil Report R R R
b. Formwork fabrication Dimensional IFC Drawing / Barbending P SW R
Civil Report
Schedule
2 Installation
 a. Location, dimension, alignment, plumb and elevation Dimensional IFC Drawing Civil Report P R R
c. Installation of embedded materials includingsetting of water-stop board Visual & Dimensional Engineering Specification / IFC P SW R
(location, elevation and rigidity) Drawing Civil Report

d. Installation of embedded materials for pipe sleeper (level, elevation, Visual & Dimensional Engineering Specification / IFC P SW R
location, length, rigidity) Drawing Civil Report

e. Stability against concrete placing and vibration (sufficiency of support, Visual Engineering Specification / IFC P SW R
shoring, form tie, etc.) Drawing Civil Report

f. Surface treatment (cleaning and form oil application) Visual Engineering Specification Civil Report P SW R
g. Protection of form scaffolding Visual Engineering Specification Civil Report P R R

10.0 ANCHOR BOLT

1 Preparation
a. Compliance of material with standard Dimensional Engineering Specification Civil Report P SW R
2 Installation
a. Location, direction, elevation and upside of template Visual & Dimensional Standard Dwg / IFC Drawing Civil Report P SW R
b. Stability of template Visual Standard Dwg / IFC Drawing Civil Report P SW R
c. Location, elevation, plumbness, size and number of anchor bolts or Visual & Dimensional Standard Dwg / IFC Drawing P SW R
anchor boxes Civil Report

d. Anchor Bolt protection against movement Visual Engineering Specification Civil Report P SW R
e. Protection and cleaning anchor bolt threads before and after placing Visual Engineering Specification P SW R
concrete Civil Report

11.0 OPEN DITCH

1 Preparation
a. Area preparation Visual Engineering Specification / IFC - P SW R
Drawing
2 Open Ditch Work
a. Excavation IFC Drawing
b. Straightness, elevation, depth, width and side slope of ditch Dimensional Engineering Spec. / IFC Drawing P SW R
Civil Report

c. Form work, rebar installation and concreting Visual & Dimensional Engineering Spec. / IFC Drawing P SW R
Civil Report

d. Surface finishing Visual Civil Report P SW R

e. Backfilling Visual & Dimensional Civil Report P SW R

12.0 ROAD & PAVEMENT

A. 1 Preparation
 a. Area preparation Visual Engineering Specification / IFC Civil Report P SW R
Drawing
2 Concrete Pavement Work
a. Form work, rebar installation and concreting Visual & Dimensional Engineering Spec. / IFC Drawing P SW R
Civil Report

b. Construction and expansion joint , Longitudinal Joint Visual & Dimensional Engineering Spec. / IFC Drawing P SW R
Civil Report

c. Surface finishing, slope, elevation and smoothness Visual & Dimensional Civil Report P SW R
d. Timing of release to traffics (provision of barricade of rope) Review Engineering spec. P SW R
e. Prohibiting heavy vehicle (such as crane, etc.) Review Engineering spec. P SW R

13.0 FENCING
1 Preparation
a. Material (conformity to specification and drawing) Visual, Dimensional & Engineering specification P R R
Review Civil Report

b. Set-out location Dimensional IFC Drawing Civil Report P SW R

2 Installation P
a. Excavation Visual Engineering specification Civil Report P SW R
b. Installation of Post (alignment, elevation, location and stability) Visual & Engineering Specification/ IFC P SW R
Drawing Civil Report

c. Form work, rebar installation and concreting Visual & Dimensional Engineering Specification/ IFC P SW R
Drawing Civil Report

d. Installation of chain link, barbed wire and tension wire Visual Engineering specification Civil Report P SW R
e. Finishing Visual Engineering specification Civil Report P SW R

14.0 GYPSUM BOARD WORK

1 Preparation
a Confirmation of material with specification and drawing Visual & Dimensional Engineering Specification/ IFC P R R
Drawing Civil Report

b. Setting of frame Visual IFC Drawing Civil Report P SW R

2 Installation
a. Layout and pattern Visual IFC Drawing Civil Report P SW R
b. Installation & fixing of board Visual Engineering Specification Civil Report P SW R
c. Cleaning & protection Visual Engineering Specification Civil Report P SW R
d. Finishing Visual Engineering Specification Civil Report P SW R

15.0 ACOUSTIC CEILING WORK

 1 Preparation
a. Confirmation of material with specification and drawing Visual & Dimensional Engineering Specification Civil Report P R R
b. Setting of frame Visual Engineering Specification Civil Report P SW R
2 Installation
a. Layout and pattern Visual IFC Drawing Civil Report P SW R
b Condition of Installation accepted Visual Engineering Specification Civil Report P SW R

16.0 STEEL STRUCTURAL WORK

1 Preparation
a. WPS Review AWS D.1.1 WPS P R R
b. Welder Qualification Test Test AWS D.1.1 Welder List P SW R
c. NDE Procedure (if needed) Review AWS D.1.1 NDE Procedure P R R
d. Material (conformity to specification and drawing) Visual & Dimensional Engineering Specification Civil Report P SW R
e. Padding / Shim Plate Visual & Dimensional IFC Drawing Civil Report P SW R
f. Determine centerline, elevation for column and beam Dimensional IFC Drawing Civil Report P SW R
2 Installation
a. Check plumbness, centerline, etc Dimensional Engineering Specification Civil Report P SW R
b. Inspection for high strength bolting Test Engineering Specification Civil Report P SW R
c. Visual inspection for weld Visual Engineering Specification Civil Report P SW R
d. Final visual inspection Visual Engineering Specification Civil Report P SW R
e. NDE ( PT , MPI or UT ) if needed Test Engineering Specification NDE Report P SW R

17.0 DOOR AND WINDOW

1 Preparation
a. Material (conformity to specification and drawing) Visual & Dimensional Engineering Specification Civil Report P SW R
b. Storage & handling of material Visual Engineering Specification P SW R
2 Installation
a. Plumbness and level Dimensional IFC Drawing Civil Report P SW R
b. Hardware installation Visual Engineering Specification Civil Report P SW R
c. Finishing Visual Engineering Specification Civil Report P SW R

18.0 WALL MASONRY WORK

1 Preparation
a. Quality and quantity of material Visual Engineering Specification Civil Report P SW R
b. Surface preparation Visual Engineering Specification Civil Report P SW R
2 Installation
a. Location, wall center, vertical batter board Dimensional IFC Drawing Civil Report P SW R
 b. Mixing proportion of mortar Visual Engineering Specification Civil Report P SW R
c. Reinforcement and other accessories (rebar, wall tie, anchor, etc.) Visual Engineering Specification Civil Report P SW R
d. Leave off laying height per one day Visual Engineering Specification NONE P SW R
e Curing Visual Engineering Specification Civil Report P SW R
f. Visual check of surface Visual Engineering Specification Civil Report P SW R

19.0 PLASTERING
1 Preparation
a. Quality of material Visual Engineering Specification Civil Report P SW R
b. Surface preparation Visual Engineering Specification Civil Report P SW R
2 Application
a. Proportioning & Mixing Visual Engineering Specification Civil Report P SW R
b. Thickness Visual Engineering Specification Civil Report P SW R
c. Finishing & Curing Visual Engineering Specification Civil Report P SW R

20.0 ROOFING AND SIDING FOR BUILDING

1 Preparation
a. Confirmation of material with specification and drawing Visual & Dimensional Engineering Specification Civil Report P SW R
b. Condition of furring (purlin, rafter, painting, etc.) Visual Engineering Specification Civil Report P SW R
2 Installation
a. Lapped joint (length and width) Dimensional IFC Drawing Civil Report P SW R
b. Caulking and sealing Visual Engineering Specification Civil Report P SW R
c. Visual check Visual Engineering Specification Civil Report P SW R

21.0 WATERPROOFING
1 Preparation
a. Concrete surface treatment (cleaning, dryness, smoothness, primer, Visual Engineering Specification P SW R
etc.) Civil Report

b. Confirmation of material with specification and drawing Visual Engineering Specification Civil Report P SW R
2 Installation
a. Condition and application of adhesive Visual Manufacturer standard NONE P SW R
b. Laying membrane and rapped joint Visual & Dimensional Engineering Specification Civil Report P SW R
c. Finishing & curing Visual Engineering Specification Civil Report P SW R
3 Test
a. Water filling (leakage) test Test Engineering Specification Civil Report P SW R

22.0 TILE WORK

1 Preparation
a. Confirmation of material with specification and drawing Visual Engineering Specification Civil Report P SW R
b. Surface Preparation Visual Engineering Specification Civil Report P SW R
2 Installation
a. Condition and application of adhesive Visual Manufacturer standard Civil Report P SW R
b. Pattern and layout Visual IFC Drawing Civil Report P SW R
c. Curing Visual Engineering Specification Civil Report P SW R
d. Cleaning & protection Visual Engineering Specification Civil Report P SW R
L WORK

REMARKS
 PONDASI
STRAUSS PILE

Tanggal :
Hal :

A. Umum

1. Proyek : 7. Rencana Pengeboran

2. Area : Kedalaman Rencana : 6,7 m - 10 m
3. Location : Tul. yang tertanam :
4. No. Gambar : h1 Panjang Tul. Vertikal :
5. Pile No. : h2 Kedalaman Lubang :
6. Diameter : h3 Sisa Tul. Vertikal :

ACCEPTED
Description Remarks
OK/Not Ok Signature
B. Pengeboran

1. Persiapan
2. Kedalaman Rencana Tulangan
Vertical
3. Diameter Galian
4. Kebersihan
h3 Galian 154.16

C. Penulangan

1. Tulangan Vertikal 6D13

2. Lap Splacing min 40D
h1
4. Sengkang Spiral Dia.8 @50
h2
D. Pengecoran

1. Pipa Tremi
2. Mutu Beton K300
3. Vibrator/Besi Rojok

E. Catatan

Print Name PT. BARATA INDONESIA PT. WIRATMAN PERUM JASA TIRTA I

Signature

Date
 INSPEKSI PEKERJAAN PENGECORAN

Project : PLTM LODAGUNG Date :

Client : Perum Jasa Tirta I Page :
Location : Reference Drawing :

RESULT
NO ITEM TO CHECK
OK NOT OK N/A
1 Kebersihan Area Pengecoran
2 Tulangan Size (diameter) & length
Overlapping length
Dowel (Number - interval)
Concrete covering thickness (Top)
Concrete covering thickness (bottom)
Spacer Spreader (pcs/m2)

3 Bekisting Kualitas papan bekisting

Posisi
Verticality
Dimension
Straightness
Bottom elevation
Top elevation (survey mark)
Chamfer

Remarks :
 PT. BARATA INDONESIA PT. WIRATMAN PERUM JASA TIRTA I
Print Name

Date
Remarks
PERUM JASA TIRTA I
 DAILY PAINTING INSPECTION REPORT

Project : PLTM LODAGUNG Report No. :

Client : PERUM JASA TIRTA I Date :
Location : PENSTOCK No. of Pages :

Climatic Condition in Work Area Condition of Steel Prior to Blasting Surface Preparation
Time : Required Actual
Air Temp. °C °C °C °C
Wet Bulb °C °C °C °C Surface Profile
Rel. Humidity % % % % Required Actual
Steel temp. °C °C °C °C Type of Abrasive : Batch No.
Dew Point °C °C °C °C Grade : Size : Dust Level :
PAINTING
WFT (Micron) DFT (Micron)
Brand Type of Batch Application
Coat No. Color Mixing Ratio Thinning Actual Actual
Name Paint No. Method Required Required
(AVG) (AVG)
m m m m

No ITEMS PAINTED No ITEMS PAINTED No ITEMS PAINTED

Note : ```
KONSORSIUM WIKA-BARATA-MSI PMC PMN
Print Name

Signature

Date
 Page 5 of 13

INSPECTION AND TEST PLAN FOR CIVIL WORK

Project : EPC Pengembangan & Modernisasi PG Asambagoes Situbondo M : Monitor P : Provide V : Verify Doc. No. :
Location : Situbondo Jawa Timur R : Review W : Witness SW : Spot Wittness Rev : 0
Client : PTPN XI H : Hold Point

RESPONSIBILITY
METHOD OF LEVEL OF ACCEPTANCE /
No. INSPECTION ACTIVITY/TEST ITEM VERIFYING DOCUMENT DISNAKE
INSPECTION REFERENCE SC WIKA PCM
R

1.0 SURVEY
A. Location, number, stability and protection of coordinates and Benchmark
Visual & Dimensional IFC Drawing Civil Report M P SW

2.0 SITE PREPARATION

a. Clearing of contaminated soil Visual Engineering Specification Civil Report P SW SW
d. Demolition Visual Engineering Specification Civil Report P SW SW
e. Debris from clearing, grubbing, stripping and demolition operation shall
be remove to disposal areas Visual Engineering Specification Civil Report P SW SW

f. Temporary Drainage Engineering Specification Civil Report P SW R

3.0 EXCAVATION
1 Preparation
a. Set location, based on shop drawing and Benchmark
Dimensional IFC Drawing Civil Report P SW R

b. Demolition or Protection of Existing Facility Visual IFC Drawing Civil Report P R R

c. Investigation of Existing under-ground Facilities Visual IFC Drawing Civil Report P R R
2 Excavation Work
a. Depth and width of excavation Dimensional IFC Drawing Civil Report P SW R
b. Line, Slope and Grades according to approved drawing Visual IFC Drawing Civil Report P R R
c. Protection of Slope, Visual Engineering Specification Civil Report P R R
d Compaction Test after excavation, confirmed Visual Engineering Specification Civil Report P W R
e. Cleaning ``` Engineering Specification Civil Report P R R

4.0 BACKFILL
 Page 6 of 13
1 Preparation
a. cleaning before backfill Visual Engineering Specification Civil Report P SW R
b. back fill material Visual Engineering Specification Civil Report P SW R
2 Placement of fill
a. Cleaning (removal of trash debris, etc.) in soil Visual Engineering Specification Civil Report P SW R
b. Filling around underground pipe and cable (if any) Visual Engineering Specification Civil Report P SW R
c. Final Elevation Dimensional IFC Drawing Civil Report P SW R
3 3 Testing
a. Compaction test by Sand cone test Test Engineering Specification Civil Report P SW R
4 4 Final Visual Inspection Visual IFC Drawing Civil Report P W R

5.0 PILING WORK

1 Preparation
a. Review Welder Qualification Review Engineering Specification Certificate P R R
b. Sequence of piling Review Engineering Specification P R R
c. Method of joint (clear spacing, end preparation, and appearance of Review Engineering Specification P R R
welding, coating, etc.) Civil Report

d. Quality of pile materials Visual Engineering Specification Civil Report M W R

e. Number and size of pile Dimensional IFC Drawing Civil Report M W R
f. PDA test procedure Review Engineering Specification Procedure P R R
2 Piling Work
a. Location of pile Dimensional IFC Drawing Civil Report P SW R
b. Check joint Test Engineering Specification Civil Report P W R
c. Kalendering of top elevation Dimensional IFC Drawing Civil Report P SW R
d. Elevation of pile head cut off Dimensional IFC Drawing Civil Report P SW R
3 Test
a. PDA Test Test Engineering Specification Test Report P W W

6.0 CONCRETE WORK

1 Preparation
a. Cement type, quality, quantity and compliance with applicable standard Test & Review Engineering Specification Mill Certificate & Laboratory P R R
Test
b. Quality and quantity of aggregate (sieve test, etc.) Test Engineering Specification Mill Certificate & Laboratory P SW R
Test
c. Mix Design Review Engineering Specification Civil Report P R R
d. Trial Mix Test Engineering Specification Civil Report P W R
f. Storing condition of cement and aggregate Visual Engineering Specification - P SW R
 Page 7 of 13
g. Location and surface condition of joints Visual & Dimensional Engineering Specification Civil Report P SW R
h. Cleaning prior to concrete placing Visual Engineering Specification Civil Report P SW R
2 Concrete Pouring
a. Workmanship of placing and consolidation (drop height, thickness of Visual Engineering Specification P W R
layer, proper vibration, etc.) Civil Report

b. Concrete finishing and removal of laitance Visual Engineering Specification Civil Report P SW R
3 Post Concrete Pouring
a. Curing (period, method of preventing moisture loss) Visual Engineering Specification Civil Report P SW R
b. Appearance of surface after form removal (honeycomb, crack, etc.) Visual Engineering Specification Punch List Report P SW R

c. Mortar finishing (level, chamber, crack, mortar proportion, etc.) Visual Engineering Specification Punch List Report P SW R

d. Dimensional inspection for completed casting Dimensional IFC Drawing Civil Report P SW R
4 Test
a. Concrete test (slump, compressive strength, etc.) Test Engineering Specification Civil Report P W R

8.0 REINFORCING BAR WORK

1 Preparation
a. Compliance of material with standard Visual & Dimensional Engineering Specification Civil Report P R R
b. Handling and storing Visual Engineering Specification - P SW R
c. Workmanship in cold bending operation Visual Engineering Specification Civil Report P SW R
d. Surface cleaning (to be free from mud, dirt, grease, loose mill, scale, Visual Engineering Specification P SW R
etc.) Civil Report

2 Installation
a. Location, shape, sizes, numbers, cleaning and spacing of bars Visual & Dimensional IFC Drawing / Barbending P SW R
Schedule Civil Report

b. Length and location of lap splice Visual & Dimensional IFC Drawing / Barbending P SW R
Schedule Civil Report

c. Rigidity of rebar assembly to withstand concrete pouring Visual Engineering Specification Civil Report P SW R
d. Strong condition (to prevent corrosion and deformation) Visual Engineering Specification Civil Report P SW R
e. Prohibiting item (welding) Visual Engineering Specification Civil Report P SW R

9.0 FORM WORK

1 Preparation
a. Quality and shape of material Visual Engineering Specification Civil Report R R R
b. Formwork fabrication Dimensional IFC Drawing / Barbending P SW R
Civil Report
Schedule
 Page 8 of 13
2 Installation
a. Location, dimension, alignment, plumb and elevation Dimensional IFC Drawing Civil Report P R R
c. Installation of embedded materials includingsetting of water-stop board Visual & Dimensional Engineering Specification / IFC P SW R
(location, elevation and rigidity) Drawing Civil Report

d. Installation of embedded materials for pipe sleeper (level, elevation, Visual & Dimensional Engineering Specification / IFC P SW R
location, length, rigidity) Drawing Civil Report

e. Stability against concrete placing and vibration (sufficiency of support, Visual Engineering Specification / IFC P SW R
shoring, form tie, etc.) Drawing Civil Report

f. Surface treatment (cleaning and form oil application) Visual Engineering Specification Civil Report P SW R
g. Protection of form scaffolding Visual Engineering Specification Civil Report P R R

10.0 ANCHOR BOLT

1 Preparation
a. Compliance of material with standard Dimensional Engineering Specification Civil Report P SW R
2 Installation
a. Location, direction, elevation and upside of template Visual & Dimensional Standard Dwg / IFC Drawing Civil Report P SW R
b. Stability of template Visual Standard Dwg / IFC Drawing Civil Report P SW R
c. Location, elevation, plumbness, size and number of anchor bolts or Visual & Dimensional Standard Dwg / IFC Drawing P SW R
anchor boxes Civil Report

d. Anchor Bolt protection against movement Visual Engineering Specification Civil Report P SW R
e. Protection and cleaning anchor bolt threads before and after placing Visual Engineering Specification P SW R
concrete Civil Report

11.0 OPEN DITCH

1 Preparation
a. Area preparation Visual Engineering Specification / IFC - P SW R
Drawing
2 Open Ditch Work
a. Excavation IFC Drawing
b. Straightness, elevation, depth, width and side slope of ditch Dimensional Engineering Spec. / IFC Drawing P SW R
Civil Report

c. Form work, rebar installation and concreting Visual & Dimensional Engineering Spec. / IFC Drawing P SW R
Civil Report

d. Surface finishing Visual Civil Report P SW R

e. Backfilling Visual & Dimensional Civil Report P SW R

12.0 ROAD & PAVEMENT

 Page 9 of 13
A. 1 Preparation
a. Area preparation Visual Engineering Specification / IFC - P SW R
Drawing
2 Concrete Pavement Work
a. Form work, rebar installation and concreting Visual & Dimensional Engineering Spec. / IFC Drawing P SW R
Civil Report

b. Construction and expansion joint , Longitudinal Joint Visual & Dimensional Engineering Spec. / IFC Drawing P SW R
Civil Report

c. Surface finishing, slope, elevation and smoothness Visual & Dimensional Civil Report P SW R
d. Timing of release to traffics (provision of barricade of rope) Review Engineering spec. P SW R
e. Prohibiting heavy vehicle (such as crane, etc.) Review Engineering spec. P SW R

13.0 FENCING
1 Preparation
a. Material (conformity to specification and drawing) Visual, Dimensional & Engineering specification P R R
Review Civil Report

b. Set-out location Dimensional IFC Drawing Civil Report P SW R

2 Installation P
a. Excavation Visual Engineering specification Civil Report P SW R
b. Installation of Post (alignment, elevation, location and stability) Visual & Engineering Specification/ IFC P SW R
Drawing Civil Report

c. Form work, rebar installation and concreting Visual & Dimensional Engineering Specification/ IFC P SW R
Drawing Civil Report

d. Installation of chain link, barbed wire and tension wire Visual Engineering specification Civil Report P SW R
e. Finishing Visual Engineering specification Civil Report P SW R

14.0 GYPSUM BOARD WORK

1 Preparation
a Confirmation of material with specification and drawing Visual & Dimensional Engineering Specification/ IFC P R R
Drawing Civil Report

b. Setting of frame Visual IFC Drawing Civil Report P SW R

2 Installation
a. Layout and pattern Visual IFC Drawing Civil Report P SW R
b. Installation & fixing of board Visual Engineering Specification Civil Report P SW R
c. Cleaning & protection Visual Engineering Specification Civil Report P SW R
d. Finishing Visual Engineering Specification Civil Report P SW R
 Page 10 of 13
15.0 ACOUSTIC CEILING WORK
1 Preparation
a. Confirmation of material with specification and drawing Visual & Dimensional Engineering Specification Civil Report P R R
b. Setting of frame Visual Engineering Specification Civil Report P SW R
2 Installation
a. Layout and pattern Visual IFC Drawing Civil Report P SW R
b Condition of Installation accepted Visual Engineering Specification Civil Report P SW R

16.0 STEEL STRUCTURAL WORK

1 Preparation
a. WPS Review AWS D.1.1 WPS P R R
b. Welder Qualification Test Test AWS D.1.1 Welder List P SW R
c. NDE Procedure (if needed) Review AWS D.1.1 NDE Procedure P R R
d. Material (conformity to specification and drawing) Visual & Dimensional Engineering Specification Civil Report P SW R
e. Padding / Shim Plate Visual & Dimensional IFC Drawing Civil Report P SW R
f. Determine centerline, elevation for column and beam Dimensional IFC Drawing Civil Report P SW R
2 Installation
a. Check plumbness, centerline, etc Dimensional Engineering Specification Civil Report P SW R
b. Inspection for high strength bolting Test Engineering Specification Civil Report P SW R
c. Visual inspection for weld Visual Engineering Specification Civil Report P SW R
d. Final visual inspection Visual Engineering Specification Civil Report P SW R
e. NDE ( PT , MPI or UT ) if needed Test Engineering Specification NDE Report P SW R

17.0 DOOR AND WINDOW

1 Preparation
a. Material (conformity to specification and drawing) Visual & Dimensional Engineering Specification Civil Report P SW R
b. Storage & handling of material Visual Engineering Specification P SW R
2 Installation
a. Plumbness and level Dimensional IFC Drawing Civil Report P SW R
b. Hardware installation Visual Engineering Specification Civil Report P SW R
c. Finishing Visual Engineering Specification Civil Report P SW R

18.0 WALL MASONRY WORK

1 Preparation
a. Quality and quantity of material Visual Engineering Specification Civil Report P SW R
b. Surface preparation Visual Engineering Specification Civil Report P SW R
2 Installation
 Page 11 of 13
a. Location, wall center, vertical batter board Dimensional IFC Drawing Civil Report P SW R
b. Mixing proportion of mortar Visual Engineering Specification Civil Report P SW R
c. Reinforcement and other accessories (rebar, wall tie, anchor, etc.) Visual Engineering Specification Civil Report P SW R
d. Leave off laying height per one day Visual Engineering Specification NONE P SW R
e Curing Visual Engineering Specification Civil Report P SW R
f. Visual check of surface Visual Engineering Specification Civil Report P SW R

19.0 PLASTERING
1 Preparation
a. Quality of material Visual Engineering Specification Civil Report P SW R
b. Surface preparation Visual Engineering Specification Civil Report P SW R
2 Application
a. Proportioning & Mixing Visual Engineering Specification Civil Report P SW R
b. Thickness Visual Engineering Specification Civil Report P SW R
c. Finishing & Curing Visual Engineering Specification Civil Report P SW R

20.0 ROOFING AND SIDING FOR BUILDING

1 Preparation
a. Confirmation of material with specification and drawing Visual & Dimensional Engineering Specification Civil Report P SW R
b. Condition of furring (purlin, rafter, painting, etc.) Visual Engineering Specification Civil Report P SW R
2 Installation
a. Lapped joint (length and width) Dimensional IFC Drawing Civil Report P SW R
b. Caulking and sealing Visual Engineering Specification Civil Report P SW R
c. Visual check Visual Engineering Specification Civil Report P SW R

21.0 WATERPROOFING
1 Preparation
a. Concrete surface treatment (cleaning, dryness, smoothness, primer, Visual Engineering Specification P SW R
etc.) Civil Report

b. Confirmation of material with specification and drawing Visual Engineering Specification Civil Report P SW R
2 Installation
a. Condition and application of adhesive Visual Manufacturer standard NONE P SW R
b. Laying membrane and rapped joint Visual & Dimensional Engineering Specification Civil Report P SW R
c. Finishing & curing Visual Engineering Specification Civil Report P SW R
3 Test
a. Water filling (leakage) test Test Engineering Specification Civil Report P SW R
 Page 12 of 13
22.0 TILE WORK
1 Preparation
a. Confirmation of material with specification and drawing Visual Engineering Specification Civil Report P SW R
b. Surface Preparation Visual Engineering Specification Civil Report P SW R
2 Installation
a. Condition and application of adhesive Visual Manufacturer standard Civil Report P SW R
b. Pattern and layout Visual IFC Drawing Civil Report P SW R
c. Curing Visual Engineering Specification Civil Report P SW R
d. Cleaning & protection Visual Engineering Specification Civil Report P SW R
 Page 13 of 13

RK

REMARKS
Page 14 of 13
Page 15 of 13
Page 16 of 13
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Page 20 of 13
 SURVEY DATA REPORT ( Backfill )

Client : PTPN XI Doc. No. :

Project : EPCC Pengembangan & Modernisasi PG Assemmbagoes Situbondo Date :
Location : Page :
Ref. Drawing :

COORD. ACTUAL ELEVATION ACTUAL

NO POINT
N E DESIGN / TOB ELEVATION 1 2 3 4 5 6 7

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
 KONSORSIUM WIKA-BARATA-MSI PMC PMN

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Signature

Date
 QI-C.0.01

ACTUAL
REMARKS
7 8
PMN TPI
 SITE PREPARATION WORK

QI-C.0.02
Project : EPCC Pengembangan & Modernisasi PG Assembagoes Doc. No. :
Client : PTPN XI Date :
Location : Page :
Reference Drawing :

RESULT
NO ITEM TO CHECK REMARKS
OK NOT OK N/A

1 Demolition or Protection of Existing Facility

2 Investigation of Existing Under Ground Facilities

3 Setout location, based on shop drawing and endorsed benchmark

4 Clearing and grubbing of original site surface

5 Top soil removing and stock pilling of original site surface

6 Land filling or land cutting to finih grade elevation

7 Detail Rip-Rap

8 Detail Temporary Lining

9 Temporary Waterway Crossing

10 Sidement Trap

11 Diversion Dike

12 Ditch Breaker

13 Slope Stability

14 Quality of Cleaning

15 Result of Compaction Test after Excavation, Confirmed

16 Quality of Backfill Mateerial, Accepted

17 Condition of Compaction, Accepted

```
18 Quality of Cleaning after Backfill, Accepted

Remarks :

N/A = NOT AVAILABLE

KONSORSIUM WIKA-BARATA-MSI PMC PMN TPI

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 PILING SURVEY DATA

Client : PTPN XI Doc. No. :

Project : EPCC Pengembangan & Modernisasi PG Assemmbagoes Situbondo Date :
Location : Page :
Ref. Drawing :

COORDINATE DIFFERENCE ACTUAL PLU

AFTER CUTTING
NO PILE NO DESIGN ACTUAL PILE
N E CUTTING LENGTH 0O
N E N E ELEVATION
 KONSORSIUM WIKA-BARATA-MSI PMC PMN

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 QI-C.0.03

PLUMBNESS ( % )
REMARKS
0O 90O
PMN TPI
 PILING SITE REPORT

Project : EPCC Pengembangan & Modernisasi PG Assembagoes Total Nos : Doc. No. :
Client : PTPN XI Cummulative : Date :
Location : Situbondo Jawa Timur Ref. Drawing : Page :

NO PILE RIG NO. NO. OF SECTION TOTAL TOP OF PILE PENETRATION TO GL 10 BLOW FOR HAMMER REM
REF. NO. 1 2 3 4 REV. ELEV. LENGTH AGL BGL SET TC SIZE
WELDED
(M) (M) (M) (M) (M)

```

KONSORSIUM WIKA-BARATA-MSI
PMC PMN T

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Signature

Date
 QI-C.1.01

REMARKS
FINAL TIP
ELEVATION

TPI
 PILE LOADING TEST RECORD

QI-C.1.02
Project : EPCC Pengembangan & Modernisasi PG AssembagoesDate :
Test Pile No. : Page :
Dated Installed : Location :
Size of Pile : Date of Testing :
Working Load : Test Load :
Length af Pile : Ground Level :
Description of Test : Kentledge System / Reaction System

Date / Test Load SETTLEMENT READING (mm) LEVEL READ Average Settlement
Time (Tons) Dial No. 1 Dial No. 2 Dial No. 3 Dial No. 4 Scale A Scale B (mm)

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 TRIAL MIX OF CONCRETE

QI-C.2.01
Project : EPCC Pengembangan & Modernisasi PG Assembagoes Date :
Client : PTPN XI Page :
Location :

Construction site
Construction section
Requirements
Impermeability to Water Class of concrete B 25
High frost resistance Required strength kg/cm 2

High frost and de-icing salt resistance Consistency k

Resistance against chemical attacks Slump cm
Cement content kg/m3
Fair faced concrete Water-cement ratio =
Pumpable concrete Max. size of aggregate mm
Early strength Air Content vol. - %
Concrete with low heat evolution Time for workability hours

Aggregate Type/Manufacturer/Quarry/Borrowpit
Cement manufacturing plant
Type / class of strength
Additive manufacturer
Type / Name

Grading curve No. k-value :

Govering water cement ratio W/Z Density kg/dm3 Volume dm3 / m3

Required water content, W
Required cement content, Z
Air Content
Aggregate total

Composition for 1 m3 Composition for m3

Materials weight of Weight of weight of mpist

Percentage Volume Spec. gravity Surface moisture
aggregate s.s.d. aggregate s.s.d. aggregate

aggregate % dm3 / m3 kg / dm3 kg / m3 kg % kg kg

Cement
Water
Weight of Fresh Concrete
Concrete admixtures
Ultra fine concrete = kg/m3 Cement = kg/m3 Aggregate < 0.25 mm kg/m3 Concrete additive = kg/m3

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 POURING CONCRETE RECORD

Project : : EPCC Pengembangan & Modernisasi PG Assembagoes Doc. No.

Location : Gudang Gula Baru Date

Cemen Type : …………………………………………………………..……… Page

Specified Strength of Concrete : ………………………Kg/cm2

Time
Date Area / Block Request No. / Vol. Delivery Order
Batch Plan On Site

```

Remarks :
Attendant's Name
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 OFO

G CONCRETE RECORD

QI-C.2.03
:

Slump Poured Total

(cm) Vol. (m3) (m3)
PMN
 CONCRETE REQUISITION

QI-C.2.04
Project : EPCC Pengembangan & Modernisasi PG Assembagoes Doc. No. :
Client : PTPN XI Date :
Location : Gudang Gula Baru Page :

Date Requested :

Time Requested : AM / PM

Pour Location :

Reference Drawing :

Design Strength : Mpa Kg/cm2

Cement Type :

Mix Design No. :

Design Slump : cm

Quantity Requested : m3

Test Cube No. : Sample

Admixture :

Equipment Requested :

Others :

REMARKS :
 KONSORSIUM WIKA-BARATA-MSI PMC PMN
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Date
 STELL STRUCTURE FABRICATION

QI-C.3.01
Project : EPCC Pengembangan & Modernisasi PG Assembagoes Date :
Client : PTPN XI Page :
Location : Reference Drawing :

RESULT
NO ITEM TO CHECK REMARKS
OK NOT OK N/A

1 Welding Procedure approved

2 NDE Test Procedure approved

3 Welders are qualified to the appropriate code and procedure

4 Materials section and size correct

5 Burns and sharps corners removed

6 Fit-up approved for welding

7 Visual inspection carried out

8 NDE as required approved

9 Dimension checked

10 Base plate and attachment are square and correctly positioned

11 Sand blasting carried out to specification

12 Paint primer and finished coat satisfacory

13

14

15

Remarks :

```
KONSORSIUM WIKA-BARATA-MSI PMC PMN

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Date
 STEEL STRUCTURE ERECTION

QI-C.3.02
Project : EPCC Pengembangan & Modernisasi PG Assembagoes Date :
Client : PTPN XI Page :
Location : Reference Drawing :

RESULT
NO ITEM TO CHECK REMARKS
OK NOT OK N/A
Receiving of material component ( Type, Size, Grade, Identification & Mill
1
Certificate )
2 Anchor bolts

3 Dimensional check of anchor bolt holes

4 Location and Plan

5 Dimensional Inspection ( level, axis, lines, perpendicular/Plumnes )

6 Bolts Specification, Tightening & Size

7 Welding ( Comsumable Control, Interpass Cleaning & Visual Appearance )

8 Visual inspection for platform grating, hand rails and ladders

9 Grouting of Base

10 Painting or galvanizing

Remarks :

```
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Date
 STEEL STRUCTURE INSPECTION FOR ERECTION

QI-C.3.03
Project : EPCC Pengembangan & Modernisasi PG Assembagoes Date :
Client : PTPN XI Page :
Location : Reference Drawing :

S U

6 5 4 3 2 1 9000
10000

1000

6000 6000 6000 6000 6000

30000
TAMPAK SAMPING

W E

B A 9000
10000

1000

18000

TAMPAK DEPAN
VERTICALITY ELEVATION
A6 to NORTH A6 to EAST A6
TOP BEST PLATE TOP BEST PLATE
TOP BOTTOM TOP BOTTOM 1 2
DESIGN 0 0 0 0 DESIGN 46720 55720
ACTUAL ACTUAL
TOLERANCE 1/500 1/500 1/500 1/500 TOLERANCE ± 3mm ± 3mm
DEVIASI DEVIASI

VERTICALITY ELEVATION
B6 to NORTH B6 to EAST B6
TOP BEST PLATE TOP BEST PLATE
TOP BOTTOM TOP BOTTOM 1 2
DESIGN 0 0 0 0 DESIGN 46720 55720
ACTUAL ACTUAL
TOLERANCE 1/500 1/500 1/500 1/500 TOLERANCE ± 3mm ± 3mm
DEVIASI DEVIASI

KONSORSIUM WIKA-BARATA-MSI PMC PMN

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 LIQUID PENETRANT TESTING REPORT

Job/Contract No. :
Project : EPCC Pengembangan & Modernisasi PG Assembagoes
Client : PTPN XI
Customer :
Lighting Equipment :
Surface Condition : As Welded Ground Flush
Stage of Examination : After Welding After Excavation
Welding Process : SMAW GTAW
Scope of Examination : Base Material Weldment
Penetrant Type : Water Washable
: √ Solvent Removable
: Post Emulsifiable
Penetrant : Fluorescent √ Colors Contrast
Developer Type : MAGNAFLUX SKD- S2 Dry Developer
Developing Time : 10 Min
Cleaner Type : MAGNAFLUX SKC- S
WELDER THK Type of
Part Identification Joint No.
STAMP MM Discontinuity

```
NOTE : NAD = NO APPARENT DISCONTINUITY

TECHNICIAN KONSORSIUM WIKA-BARATA-MSI PMC PMN

Name : Name : Name : Name :

Date : Date : Date : Date :
ID PENETRANT TESTING REPORT

Report No. :
Ref. Drawing No. :
Material Examined :
Illumination Level : 1000 LUX

Other
Other
Other
Other
Application by :
Brushing √ Spraying Other
Dwell Time: 5 - 10 Min

Aqueous Dev. √ Non Aqueous Dev.

Procedure No. :
Applicable Code :

Result Remark
PMN
 BOLT TIGTHENING INSPECTION REPORT

QI-C.3.04
PROJECT : EPCC Pengembangan & Modernisasi PG AssembagoDate :
CLIENT : PTPN XI Page :
LOCATION : Bolt Material :
Equipment : Area / Unit :
Item No. : Size Bolt :
Drawing :

BOLT REQUIRED TORQUE ACTUAL TORQUE SKETCH

NUMBER (UNIT) (Unit)

RESULT : Acceptable Not Acceptable

Remarks :

KONSORSIUM WIKA-BARATA-MSI PMC PTPN XI

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Signature

Date
 WALL MASONRY WORK

QI-C.4.01
Project : EPCC Pengembangan & Modernisasi PG Assembagoes Date :
Client : PTPN XI Page :
Location : Reference Drawing :

RESULT
NO ITEM TO CHECK REMARKS
OK NOT OK N/A

1 Subsurface Treatment Accepted

2 Quality of Material Accepted

3 Protection for Weather Accepted

4 Proportioning and Mixing Mortar Accepted

Reinforcement and Installation of Accessories ( Horizontal
5
Dowels, Veltical Dowels, etc)
6 Installation of Column Practice Accepted

7 Opening / Sleeve Accepted

8 Surface Condition of Application Accepted

9 Condition of Trowel Finish Accepted

10 Condition of Curing Accepted

11

12

13

14

15

Remarks :

````

KONSORSIUM WIKA-BARATA-MSI PMC PMN

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Signature

Date
 PLASTERING WORK

QI-C.4.02
Project : EPCC Pengembangan & Modernisasi PG Assembagoes Date :
Client : PTPN XI Page :
Location : Reference Drawing : :

RESULT
NO ITEM TO CHECK REMARKS
OK NOT OK N/A

1 Subsurface Treatment Accepted

2 Quality of Material Accepted

3 Protection for Weather Accepted

4 Proportioning and Mixing Accepted

5 Application of First Coat Accepted

6 Application of Second Coat Accepted

7 Application of Third Coat Accepted

8 Surface Condition of Application Accepted

9 Condition of Trowel Finish Accepted

10 Condition of Curing Accepted

Remarks :

```
KONSORSIUM WIKA-BARATA-MSI PMC PMN

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Signature

Date
 TILE WORK

QI-C.4.03
Project : EPCC Pengembangan & Modernisasi PG Assembagoes Date :
Client : PTPN XI Page :
Location : Reference Drawing :

RESULT
NO ITEM TO CHECK REMARKS
OK NOT OK N/A

1 Surface Preparation Accepted

2 Quality of Material Accepted

3 Weather Condition Accepted

4 Condition and Application of Adhesive Accepted

5 Pattern and Layout of Installation Accepted

6 Curing Condition Accepted

7 Condition of Washing and Cleaning Accepted

8 Drainable Slope Acceptable

Remarks :

```
KONSORSIUM WIKA-BARATA-MSI PMC PMN

Print Name

Signature

Date
 DOOR & WINDOW WORKS

QI-C.4.04
Project : EPCC Pengembangan & Modernisasi PG Assembagoes Date :
Client : PTPN XI Page :
Location : Reference Drawing :

RESULT
NO ITEM TO CHECK REMARKS
OK NOT OK N/A

1 Type and Condition of Materials Accepted

2 General Operation of Door / Window

3 Installation of Frames anchored Plumb and Level Accepted

4 Hardware in Good Mechanical Operation

5 Glass Well Bedded and Putty Neatly Trimmed

Operatiom of Overhead or Telescoping Doors / Windows (controls,
6
smoothness and speed)
7 Telescoping Door Guides Installed, secured and aligned

8 Installation of Hardware Accepted

9 Instruction Manuals for Special Checked

Remarks :

```
KONSORSIUM WIKA-BARATA-MSI PMC PMN
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Signature

Date
 GYPSUM BOARD INSTALLATION

QI-C.4.05

Project : EPCC Pengembangan & Modernisasi PG Assembagoes Date :

Client : PTPN XI Page :

Location : Reference Drawing : :

RESULT
NO ITEM TO CHECK REMARKS
OK NOT OK N/A

1 Subsurface Preparation Accepted

2 Preparation of Setting Frame Accepted

3 Quality of Material Accepted

4 Marking Approved

5 Application of Board Approved

6 Treatment of Joint Area Accepted

7 Treatment of Surface Accepted

8 Layout and Pattern of installation accepted

9 Curing Condition Accepted

10 Condition Cleaning and Protection Accepted

Remarks :

```
KONSORSIUM WIKA-BARATA-MSI PMC PMN
Print Name

Signature

Date
 ACOUSTIC BOARD INSTALLATION

QI-C.4.06
Project : EPCC Pengembangan & Modernisasi PG Assembagoes Date :
Client : PTPN XI Page :
Location : Reference Drawing :

RESULT
NO ITEM TO CHECK REMARKS
OK NOT OK N/A

1 Subsurface Preparation Accepted

2 Preparation of Setting Frame Accepted

3 Quality of Material Accepted

4 Marking Approved

5 Application of Board Approved

6 Treatment of Joint Area Accepted

7 Treatment of Surface Accepted

8 Layout and Pattern of installation accepted

9 Curing Condition Accepted

10 Condition Cleaning and Protection Accepted

11

12

13

14

15

Remarks :

```
KONSORSIUM WIKA-BARATA-MSI PMC PMN

Print Name

Signature

Date
 WATER PROOFING PROTECTION

QI-C.4.07
Project : EPCC Pengembangan & Modernisasi PG Assembagoes Date :
Client : PTPN XI Page :
Location : Reference Drawing :

RESULT
NO ITEM TO CHECK REMARKS
OK NOT OK N/A

1 Subsurface Preparation Accepted

2 Quality of Material Accepted

3 Weather Condition Accepted

4 1st Layer Accepted

5 2nd Layer Accepted

6 3rd Layer Accepted

7 Curing Condition Accepted

8 Leakage Test Accepted

Remarks :

```
KONSORSIUM WIKA-BARATA-MSI PMC PMN
Print Name

Signature

Date
 ASPALT WATER PROOFING WORK

QI-C.4.08
Project : EPCC Pengembangan & Modernisasi PG Assembagoes Date :
Client : PTPN XI Page :
Location : Reference Drawing :

RESULT
NO ITEM TO CHECK REMARKS
OK NOT OK N/A

1 Climatic Condition Accepted

2 Surface Condition of Setting Bed Accepted

3 Amount, Equality and Dryness Period of Primer Accepted

4 Location, Safety, Tempaerature and Time of Melting Asphalt Accepted

5 Application of Melting Asphalt Accepted

6 Number of Roofing Layer Accepted

7 Lapping Part of Roofing Accepted

8 Treatment for Cumple of Roofing Accepted

9 Leakage Accepted

10

11

12

13

14

15

Remarks :

```
KONSORSIUM WIKA-BARATA-MSI PMC PMN
Print Name

Signature

Date
 ROOFING & SIDING

QI-C.5.01
Project : EPCC Pengembangan & Modernisasi PG Assembagoes Date :
Client : PTPN XI Page :
Location : Reference Drawing :

RESULT
NO ITEM TO CHECK REMARKS
OK NOT OK N/A

1 Condition of Matrial Accepted

2 Preparation of Framing Accepted

3 Dimensional (Size, Elevation & Slope)

4 Installation of Accessories Accepted

5 Condition of Fastening Accepted

6 Condition of Cleaning Accepted

10

11

12

13

14

15

Remarks :

```
KONSORSIUM WIKA-BARATA-MSI PMC PMN

Print Name

Signature

Date
 ROAD & PAVEMENT (RIGID)

QI-C.5.02
Project : EPCC Pengembangan & Modernisasi PG Assembagoes Date :
Client : PTPN XI Page :
Location : Reference Drawing :

RESULT
NO ITEM TO CHECK REMARKS
OK NOT OK N/A

1 Condition of Subgrade Accepted

2 Installation of Plastic Sheet Accepted

3 Installation of Formwork Accepted

4 Installation of Reinforcement Accepted

5 Installation of Expansion Joint Accepted

6 Condition of Cleaning Accepted

7 Placing Concrete

8 Drainable Slope Acceptable

9 Condition of Curing Accepted

10 Condition of Cleaning Accepted

Remarks :

```
KONSORSIUM WIKA-BARATA-MSI PMC PMN
Print Name

Signature

Date
 ASPALT CONCRETE

QI-C.5.03
Project : EPCC Pengembangan & Modernisasi PG Assembagoes Date :
Client : PTPN XI Page :
Location : Reference Drawing :

RESULT
NO ITEM TO CHECK REMARKS
OK NOT OK N/A

I BASE COURSE
Base Course Ready to spread of asphalt concrete as per Inspection
1
sequence before
II BITUMINOUS PRIME COAT

1 Prime Coat Composition and materials have been approved

2 The surface of base course

3 Spread Prime Coat

4 Check the surface after spreading of Prime Coat

III HOT ASPALT MIXTURE / ASPALT CONCRETE

1 Asphalt Concrete composition and materials have been approved

2 Equipments will be used have been acepted and ready to use

3 Check temprature of Asphalt Concrete on Site before spreading

4 Place and spread Asphalt Concrete as per designe requirement

5 Compact Asphalt Concrete have been spread with tire roller

6 Check Composition density and thickness

7 Final survey

Remarks :

```
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Date
 OPEN DITCH

QI-C.6.01
Project : EPCC Pengembangan & Modernisasi PG Assembagoes Date :
Client : PTPN XI Page :
Location : Reference Drawing :

RESULT
NO ITEM TO CHECK REMARKS
OK NOT OK N/A

1 Excavation ( Location & Elevation )

2 Field Compaction test Accepted

3 Reinforcement Installation Accepted

4 Formwork Installation Accepted

5 Embedments Installation Accepted

6 Concrete

7 Removal of Formwork

8 Drainable Slope Acceptable

9 Water Flow test Accepted

10

11

12

13

14

15

Remarks :

```
KONSORSIUM WIKA-BARATA-MSI PMC PMN
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Signature

Date
```
```
 CHECK LIST MOS BORED PILE

QI-C.0.03
Client : PTPN XI Doc. No.
Project : EPCC Pengembangan & Modernisasi PG Assembagoes Date
Location : Page
Ref. Drawi :

No Item kondisi Umur Beton Dimensional Spesifikasi Quantity

Accept Rejeck

KONSORSIUM WIKA-BARATA-MSI PMC PMN

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Signature

Date
 INSPEKSI PEKERJAAN PEMASANGAN PIPA PENSTOCK

Project : PLTM LODAGUNG Date :

Client : Perum Jasa Tirta I Page :
Location : Reference Drawing :

RESULT
NO ITEM TO CHECK
OK NOT OK N/A
1 Kebersihan Area Dalam
2 Kebersihan Area Luar
3 Intalasi Diameter
Gasket
Nut + Washer
4 Painting Spek. Cat
Warna
Bahan Tambah
5 Material

Remarks :
 PT. BARATA INDONESIA PT. WIRATMAN PERUM JASA TIRTA I
Print Name

Date
Remarks
PERUM JASA TIRTA I