INSPECTION REQUEST FORM

Flsmidth A/S Xuan thanh

INSPECTION REQUEST NUMBER: REV.# DATE OF REQUEST:

DATE / TIME OF INSPECTION :

CONTRACTOR / SUB-CON: DIVISION: FLS ITEM NUMBER :

REFERENCES , DOCUMENT NUMBERS , LOCATION AND ANY REMARKS

Specification General Workshop Instruction No. 520530
Drawing(s)
Method Statement
Location/Building
ITEM OR ACTIVITY TO BE INSPECTED LOCATION ELEVATION TYPE OF INSPECTION
LILAMA

Quantity
Category Subcategory Element / Structure
Amount Unit of Measurement

Other department activity acceptance (Name and Signature or N/A as required)

Civil Safety Electrical Mechanical

Lilama Xuan Than Coninco MI

Signature
Name
Date
Remarks / Recommendations:

Witness & Review

STATUS:

Acceptable Cancelled Accepted with Comments Rejected

Reason for Rejection :
No IFC Unsatisfactory work Not ready for inspection Work not compliant with specs / drawings
No Equipment Insufficient documentati Previous activity/item not accepted Test Failed
Others

Notes:
1. This document shall not be used to specify acceotance of the test; this can only be achieved by sign off of appropriate check sheets
shall be hereto.

2. FLS Inspection shall occur only after the inspection report is signed off by Lilama, confirming their acceptance of the work.

Disclaimer: PERMISSION TO PROCEED THE WORK SHALL NOT CONSTITUTE ACCEPTANCE OR APPROVAL OF DESIGN
DETAILS,CALCULATIONS,ANALYSIS, TEST METHODS, OR MATERIALS DEVELOPED OR SELECTED BY LILAMA AND SHALL NO
RELIEVE FROM FULL COMPLIANCE WITH CONTRACT TECHNICAL SPECIFICATIONS AND DRAWINGS.
 Lilama

MARKS

ECTION
FLS

Element / Structure

uired)
Instumentation

FLS

Review only

NCR Raised & No.

pliant with specs / drawings

of appropriate check sheets which

tance of the work.

PROVAL OF DESIGN
BY LILAMA AND SHALL NOT
GS.
Employer: XT Project: 14-45344 XT
XUAN THANH - VIETNAM 12500 tpd line

Supplier Contractor Supervisor Client

FLS LILAMA CONICON-MI XUAN THANH

FINAL MECHANICAL FIELD INSPECTION REQUEST (FFIR)

1st 2nd 3rd Inspection Inspection Date/Time

Subject to inspection

Area/ Department

Equipment Number

FLS Comments:

Inspection Approval status

APP AAN NA

Representatives Name Date

LILAMA

XUAN THANH

FLS

CONINCO MI
 XT

Ref. No.

Issue Date

ST (FFIR)

Signature