SURAT PERNYATAAN PEMANFAATAN NOMOR REGISTRASI/APPROVAL NUMBER

Saya yang bertandatangan di bawah ini :

Nama : Irsan Sudargo

Jabatan : Direktur
Alamat UPI : Jalan Pulau Sumatera, Kelurahan Mabar, Kec. Medan Deli,
Medan - Sumatera Utara, Kawasan Industri Medan I (KIM I)

Menyatakan bahwa setelah mendapatkan Nomor Registrasi/Approval Number, kami akan

memanfaatkan Nomor Registrasi/Approval Number tersebut dengan melakukan ekspor ke negara
yang bersangkutan (China).

Apabila dalam kurun waktu 1 tahun sejak diberikan nomor registrasi tersebut, kami tidak
memanfaatkannya, maka kami bersedia untuk dilakukan pembekuan/pencabutan terhadap nomor
registrasi tersebut.

Demikian surat pernyataan ini kami buat dengan sadar dan tanpa tekanan dari pihak manapun juga.

Medan, 11 Juli 2019

Irsan Sudargo
Direktur
 Appendix 3
Summary Food Hygine and Safety Conditions of
The Food Business Operator

1. Business Name : PT Toba Surimi Industries

2. Addess : Jl. Pulau Sumatera Kelurahan Mabar, Kecamatan Medan Deli,
Medan – Sumatera Utara, Kawasan Industri Medan I (KIM I)
3. Product : Frozen Seafood Cocktail
4. Production Conditions : Frozen (product chain and Export )
a. Farming and processing areas : -
b. Farming, harvesting, preparation : -
And processing methods
c. Feed handling and control measure : -
Applied in farming process
d. Packing (labeling), transport and : Inner Packing : Bag
Distribution medtod Outter Packing : Master Carton
Label/specification : - Name of Product
- Keep Frozen Below -180C
- Net Weight
- Country Of Origin
5. Quality Management : 1. Pre Request Program
a. SSOP ( attachment)
b. GMP (attachment)
2. Determined CCP at the stage of (attachment)
3. Traceability is carried out by tagging system as follow (attachment)
4. Pre Request program was approved by CA with number :
Frozen Seafood Cocktail : 9757/12/SKP/BK/IX/2018
5. HACCP was approved by CA with number :
Frozen Cocktail : 072/SM/HACCP/PB/10/18

Appendix 3
 Summary Food Hygine and Safety Conditions of
The Food Business Operator

1. Business Name : PT Toba Surimi Industries

2. Addess : Jl. Pulau Sumatera Kelurahan Mabar, Kecamatan Medan Deli,
Medan – Sumatera Utara, Kawasan Industri Medan I (KIM I)
3. Product : Frozen Shrimp
4. Production Conditions : Frozen (product chain and Export )
e. Farming and processing areas : -
f. Farming, harvesting, preparation : -
And processing methods
g. Feed handling and control measure : -
Applied in farming process
h. Packing (labeling), transport and : Inner Packing : Bag
Distribution medtod Outter Packing : Master Carton
Label/specification : - Name of Product
- Keep Frozen Below -180C
- Net Weight
- Country Of Origin
5. Quality Management : 1. Pre Request Program
a. SSOP ( attachment)
b. GMP (attachment)
2. Determined CCP at the stage of (attachment)
3. Traceability is carried out by tagging system as follow (attachment)
4. Pre Request program was approved by CA with number :
Frozen Shrimp : 9756/12/SKP/BK/IX/2018
5. HACCP was approved by CA with number :
Frozen Shrimp : 073/SM/HACCP/PB/10/18
 Appendix 3
Summary Food Hygine and Safety Conditions of
The Food Business Operator

1. Business Name : PT Toba Surimi Industries

2. Addess : Jl. Pulau Sumatera Kelurahan Mabar, Kecamatan Medan Deli,
Medan – Sumatera Utara, Kawasan Industri Medan I (KIM I)
3. Product : Frozen Cephalopod
4. Production Conditions : Frozen (product chain and Export )
i. Farming and processing areas : -
j. Farming, harvesting, preparation : -
And processing methods
k. Feed handling and control measure : -
Applied in farming process
l. Packing (labeling), transport and : Inner Packing : Bag
Distribution medtod Outter Packing : Master Carton
Label/specification : - Name of Product
- Keep Frozen Below -180C
- Net Weight
- Country Of Origin
5. Quality Management : 1. Pre Request Program
a. SSOP ( attachment)
b. GMP (attachment)
2. Determined CCP at the stage of (attachment)
3. Traceability is carried out by tagging system as follow (attachment)
4. Pre Request program was approved by CA with number :
Frozen Cephalopod : 8027/12/SKP/BK/2018
5. HACCP was approved by CA with number :
Frozen Cephalopod : 029/SM/HACCP/PB/08/18