Number: MS-0041015_01

Revision: 2
Effective date:
Author:
2023 Mar 1
Filda Aisha
Management System
Approver: Mohammed Dkhissi Template
Process Owner: Holger Kunz

Test Request Form

APPLICANT
PT Eco Laundry Hijau Indonesie Company name: *
Karangwaru, RT 28A RW 007, Krikilan, Masaran Sragen Address: *
0271 8200 200 Phone: Tax number:
wsugiarta@ptecolau
E-mail: Warih Sugiarta Contact person:
ndry.com
same as APPLICANT (invoice to be sent) FINANCING
PT Eco Laundry Hijau Indonesie Company name: *
Karangwaru, RT 28A RW 007, Krikilan, Masaran Sragen Address: *
0271 8200 200 Phone: Tax number:
wsugiarta@ptecolaun
E-mail: Warih Sugiarta Contact person:
dry.com

DISCHARGE TYPE OF WASTE WATER*

✘ On-site zero liquid discharge (ZLD System)
Direct discharged waste water with name of waterbody (river, pond, etc): …………………………………………………
Indirect discharged without pre-treatment with name of centralized effluent plant: ………………………………………..
Indirect discharged with pre-treatment with name of centralized effluent plant: ……………………………………………

AVERAGE TOTAL INDUSTRIAL WASTEWATER GENERATED *

✘ ≥15 m3 per day <15 m3 per day
Total wastewater generated in 12 months: 36542,9 Total wastewater generated in 12 months: ………………
Total working days in 12 months: 297 Total working days in 12 months: …………………………
SLUDGE DISPOSAL PATHWAY*

E - Offsite Incineration and Building Products A - Offsite Incineration at >1000oC

Processed at <1000oC B - Landfill with Significant Control Measures
F - Landfills with No Control Measures C - Building Products Processed at >1000oC
G - Land Application D - Landfill with Limited Control Measures

TEST REQUESTED*
✘ Full parameters according to Zero Discharge Hazardous Chemical Wastewater Guideline (ZDHC WWG V2.1)

Individual test (please specify the test parameters):

Table 1 (ZDHC MRSL Parameters): …………………………………………………………………………………………………
Table 2 (ZDHC Heavy Metals Parameters): ………………………………………………………………………………………..
Table 3 (ZDHC Conventional Parameters): ……………….………………………………………………………………………..
Table 4 (ZDHC Sludge Parameters: …………………………………………………………………………………………………
Specific buyer requirement (please specify buyer name): Lululemon
Others:

REPORTING OPTIONS*
Test report
✘ ZDHC Gateway
IPE Detox

Please ensure to include page 2 when submitting the signed TRF.

*Authorized Signature and Company Stamp: Date:

* The data marked with an asterisk need to be given in the same form as required on the test report. We request the above testing
and/or services and agree that all testing and/or services will be carried out subject to TUV Rheinland’s scale of charges and
turnaround times as set forth in the current price list at the time of testing and/or service delivery.

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