PT SGS Indonesia

Cilandak Commercial Estate #108C

Cilandak, Jakarta Selatan INSPECTION REPORT
Indonesia, 12560
+62 21 7818111 ..../IND/ID/VI-15
Inspection report N°:
June 19th, 2015
Report submission date:

Internal Work Order

Inspection Instruction
Visual and Function
Inspection of 3 Units
A. Project: B. Supplier: PT. Sumitomo SHI
Hydraulic Excavator
SH210-5
Project Ref. No.: Details:
P.O. Ref No: Job No.:
C. Inspection D. Sub-
Pre-Shipment Inspection -
: Supplier:
Customer Ref.No.: Details:
Int. Ref. No. (EA): Job No.:
F. Place of Jl. Port NYK Puninar - Cakung
E. Customer: PT. Sumitomo SHI Cilincing
Inspection:
Country: Indonesia Contact Person: Mr. Heri Susilo
Wisma GKBI Lt. 16 Suite 1606
Customer Ref. No.: Address: Jl. Jend. Sudirman No. 28
Jakarta Pusat 10210
Phone/Fax: +628118771254
G. Executing SGS Email-Address: susilo_heri@scm.shi.co.jp
PT SGS INDONESIA
office data:
Country: Indonesia P.O. at supplier:
Coordinator: Mr. Victor Rizal

H. Inspection Type: Spot inspection Project inspection

Pre-production During prodution Pre-Shipment

I. Scope of Work: Requested

Performed Comments
inspect witness review
According to the approved ITP No.

Pre-Shipment Inspection
Hydrostatic Test
Pre-Inspection Meeting
Final Testing/Inspection
Others
Others: (as specified):
Further description:

J. Equipment/Goods 3 Units Hydraulic Excavator SH210-5 Deviations during

Requested for Inspection: inspection:
NO
(if yes, see report details)
K. Applicable Norms, - Manufacture Certificate Verified during
Standards and - Manual Book inspection:
specifications:
- Packing List

Rev. Attached to At place of Document

L. Referenced Documents: Reference No.
No. request inspection used
Purchase Order
Purchase Order Specifications
Purchasers Standards
Data Sheet
Approved Drawings
Inspection Test Plan
Test Procedures
Weld Procedures Specifications
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 PT SGS Indonesia
Cilandak Commercial Estate #108C
Cilandak, Jakarta Selatan INSPECTION REPORT
Indonesia, 12560
+62 21 7818111 ..../IND/ID/VI-15
Inspection report N°:
June 19th, 2015
Report submission date:

Weld Procedure Approval

Certificates
Welder Approval Certificates
Operational/Functional Test
Procedures
NDE Procedures
Post Heat Treatment Procedure
Others

M. Inspection Dates: June 19th, 2015

N. No.of inspection man days:
(based on 8h)
1 (One) day

O. Inspection Result: satisfactory P. NCR/Punch list

conditionally accepted (see reportdetails) issued:
non conforming(see report details) No
rejected(see report details) Yes
abortedinspections(see report details) (see report details)

Q. Inspection Summary and - 3 units Hydraulic Excavators is new equipment and it is in

Short Conclusion: good condition.
- 3 unit Excavator is loaded to 3 flat track and 3 Truck.
- The function test is already performed and the result is
good.
- See the inspection performed and result for details.

Inspector: Mr. Jabi Tomas Sihaloho Date: June 19th, 2015

Reviewer: Mr. Victor Rizal Date: June 19th, 2015

R. Report Details

R.1. Attendees
Mr. Jabi Tomas Sihaloho (PT SGS Indonesia – Site Inspector)
Mr. Heri Susilo (PT Sumitomo SHI –Sales Marketing& Export-Import Staff)
R.2. Documents Used
- Manufacture Inspection Certificate
-Packing List
R.3. Equipment / Goods Inspected
- 3 Units Hydraulic Excavator SH210-5
R.4. Inspection activities and Results
INSPECTION PERFORMED AND RESULT
Visited to the yard to perform pre-shipment inspection which included visual inspection and function
test of 3 units Hydraulic excavator belongs to PT. Sumitomo on Friday 19.06.2015.

The purpose of this visit is to check the physically condition of 3 units Hydraulic excavator before
shipment. The inspection is also to see the function of main part, prime mover, electrical system,
and Hydraulic system and safety device of Hydraulic excavator.

The item which is inspected are the following:

1. Hydraulic excavator serial no: STN210F5C00BH5037 ; engine no : 4HK1-730575

2. Hydraulic excavator serial no: STN210F5C00BH5040 ; engine no : 4HK1-728687
3. Hydraulic excavator serial no: STN210F5A00BH5042 ; engine no : 4HK1-730199
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 PT SGS Indonesia
Cilandak Commercial Estate #108C
Cilandak, Jakarta Selatan INSPECTION REPORT
Indonesia, 12560
+62 21 7818111 ..../IND/ID/VI-15
Inspection report N°:
June 19th, 2015
Report submission date:

For the detail result please see the checklist attachment.

Inspection result and summary as below:

 Model of 3 units Hydraulic excavator is SH210-5

 Visually the Hydraulic excavator is good condition on external and internal.
 Bolting circle assembly is complete.
 Hydraulic hose and machine hose in good condition.
 Hydraulic system and swing circle assembly is in good condition
 Function test has performed to some test such as swing motion, engine on off, lamp, radio
and ac.
 3 units hydraulic excavator has been loaded to 3 units of flat track
 Standard Accessories complete.

Inspection description Result

R.4.1. Witness
- Visual Inspection (physically): Visual checking the physic of Satisfactory
Hydraulic excavator. No dent was found. Physically in good
condition.
Satisfactory
- Function Test: the prime mover part was function properly. No
leakage in Hydraulic tank. Hydraulic and electrical system testing
was already performed, and the result is good.

R.5. Non Conformities

-
R.6. Actions required
-
R.7. Conclusion
Inspection is required in order to make sure that the Hydraulic excavator is in good condition and the
function of all part is work properly.

Prepared by: Mr. Jabi Tomas Sihaloho Reviewed by: Mr. Victor Rizal
Signed: Signed:

Date of reporting: June 19th, 2015 Date of reporting: June 19th, 2015

R.8. Attachments
1. Packing List.
2. Manufacture Inspection Certificate
3. Visual Inspection Checklist.

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 PT SGS Indonesia
Cilandak Commercial Estate #108C
Cilandak, Jakarta Selatan INSPECTION REPORT
Indonesia, 12560
+62 21 7818111 ..../IND/ID/VI-15
Inspection report N°:
June 19th, 2015
Report submission date:

S. Inspection Photos

 Hydraulic excavator serial no: STN210F5C00BH5037 ; engine no : 4HK1-730575

Excavator Name Plate Engine Name Plate

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 PT SGS Indonesia
Cilandak Commercial Estate #108C
Cilandak, Jakarta Selatan INSPECTION REPORT
Indonesia, 12560
+62 21 7818111 ..../IND/ID/VI-15
Inspection report N°:
June 19th, 2015
Report submission date:

Main Body Unit Excavator Sumitomo Destination Port Marking

Boom and Arm Bucket

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 PT SGS Indonesia
Cilandak Commercial Estate #108C
Cilandak, Jakarta Selatan INSPECTION REPORT
Indonesia, 12560
+62 21 7818111 ..../IND/ID/VI-15
Inspection report N°:
June 19th, 2015
Report submission date:

Crawler Counter Weight Body

Motor Travel Breaker Piping

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 PT SGS Indonesia
Cilandak Commercial Estate #108C
Cilandak, Jakarta Selatan INSPECTION REPORT
Indonesia, 12560
+62 21 7818111 ..../IND/ID/VI-15
Inspection report N°:
June 19th, 2015
Report submission date:

Bucket (dismantle) Hydraulic System

 Hydraulic excavator serial no: STN210F5C00BH5040 ; engine no : 4HK1-728687.

Excavator Name Plate Engine Name Plate

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 PT SGS Indonesia
Cilandak Commercial Estate #108C
Cilandak, Jakarta Selatan INSPECTION REPORT
Indonesia, 12560
+62 21 7818111 ..../IND/ID/VI-15
Inspection report N°:
June 19th, 2015
Report submission date:

Unit Excavator Sumitomo (Main Body) Excavator Engine

Accessories Destination Port Marking

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 PT SGS Indonesia
Cilandak Commercial Estate #108C
Cilandak, Jakarta Selatan INSPECTION REPORT
Indonesia, 12560
+62 21 7818111 ..../IND/ID/VI-15
Inspection report N°:
June 19th, 2015
Report submission date:

Working Lamp, Wiper, Cabin Operator, Hydraulic Cylinder Counter Weight Body, Exhaust

Crawler Wheels Swing Bearing

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 PT SGS Indonesia
Cilandak Commercial Estate #108C
Cilandak, Jakarta Selatan INSPECTION REPORT
Indonesia, 12560
+62 21 7818111 ..../IND/ID/VI-15
Inspection report N°:
June 19th, 2015
Report submission date:

MotorTravel Bucket

A. Hydraulic excavator serial no: STN210F5A00BH5042 ; engine no : 4HK1-730199

Excavator Name Plate Engine Name Plate

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 PT SGS Indonesia
Cilandak Commercial Estate #108C
Cilandak, Jakarta Selatan INSPECTION REPORT
Indonesia, 12560
+62 21 7818111 ..../IND/ID/VI-15
Inspection report N°:
June 19th, 2015
Report submission date:

Unit Excavator Sumitomo (Main Body) Excavator Engine

Cabin Destination Port Marking

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 PT SGS Indonesia
Cilandak Commercial Estate #108C
Cilandak, Jakarta Selatan INSPECTION REPORT
Indonesia, 12560
+62 21 7818111 ..../IND/ID/VI-15
Inspection report N°:
June 19th, 2015
Report submission date:

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 PT SGS Indonesia
Cilandak Commercial Estate #108C
Cilandak, Jakarta Selatan INSPECTION REPORT
Indonesia, 12560
+62 21 7818111 ..../IND/ID/VI-15
Inspection report N°:
June 19th, 2015
Report submission date:

Working Lamp, Wiper, Cabin Operator, Hydraulic Cylinder Counter Weight Body, Exhaust

Crawler Wheels Host

MotorTravel Bucket

 FunctionTest and Loading Photografic Report

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 PT SGS Indonesia
Cilandak Commercial Estate #108C
Cilandak, Jakarta Selatan INSPECTION REPORT
Indonesia, 12560
+62 21 7818111 ..../IND/ID/VI-15
Inspection report N°:
June 19th, 2015
Report submission date:

Travel Motion Swing and hydraulic Motion

Swing and hydraulic Motion Funtion test

Loading to Flat Track Loading to Flat Track

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 PT SGS Indonesia
Cilandak Commercial Estate #108C
Cilandak, Jakarta Selatan INSPECTION REPORT
Indonesia, 12560
+62 21 7818111 ..../IND/ID/VI-15
Inspection report N°:
June 19th, 2015
Report submission date:

Loading Flat track to truck Loading Flat track to truck

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 PT SGS Indonesia
Cilandak Commercial Estate #108C
Cilandak, Jakarta Selatan INSPECTION REPORT
Indonesia, 12560
+62 21 7818111 ..../IND/ID/VI-15
Inspection report N°:
June 19th, 2015
Report submission date:

„Error: Reference source not found Page 16 of 11

 PT SGS Indonesia
Cilandak Commercial Estate #108C
Cilandak, Jakarta Selatan INSPECTION REPORT
Indonesia, 12560
+62 21 7818111 ..../IND/ID/VI-15
Inspection report N°:
June 19th, 2015
Report submission date:

Loading Flat track to truck Loading Flat track to truck

Loading Flat track to truck Loading Flat track to truck

Loading Flat track to truck Loading Flat track to truck

This document is issued by the Company under its General Conditions of Service accessible at http://www.sgs.com/terms_and_conditions.htm. Attention is
drawn to the limitation of liability, indemnification and jurisdiction issues defined therein.

Any holder of this document is advised that information contained hereon reflects the Company’s findings at the time of its intervention only and within the limits of
Customer’s instructions, if any. The Company’s sole responsibility is to its Customer and this document does not exonerate parties to a transaction from
exercising all their rights and obligations under the transaction documents. Any unauthorized alteration, forgery or falsification of the content or appearance of this
document is unlawful and offenders may be prosecuted to the fullest extent of the law.
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 PT SGS Indonesia
Cilandak Commercial Estate #108C
Cilandak, Jakarta Selatan INSPECTION REPORT
Indonesia, 12560
+62 21 7818111 ..../IND/ID/VI-15
Inspection report N°:
June 19th, 2015
Report submission date:

THE ABOVE REFLECTS OUR FINDINGS AT TIME AND PLACE OF INSPECTION. THIS REPORT DOES NOT
RELEASE BUYERS OR SELLERS FROM THEIR CONTRACTUAL RESPONSIBILITIES NOR DOES IT
PREJUDICE BUYER’S RIGHT OF CLAIM TOWARD SELLERS/SUPPLIERS FOR COMPENSATION FOR ANY
APPARENT AND/OR HIDDEN DEFECTS NOT DETECTED DURING OUR INSPECTION OR OCCURRING
THEREAFTER.

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