CLEARANCE TO MOVE HEAVY EQUIPMENT

CERTIFICATE
F-007/B-013/PHE020/2017-S9
(SERTIFIKAT IZIN PEMINDAHAN PERALATAN BERAT)
A. APPLICATION (APLIKASI)
Location (Lokasi) :
PTW No. :
Reason (Alasan) :
Load (Beban) :
Equipment (Alat) :

Dimension (Dimensi) :
Weight (Berat) :
Route (Rute) :

Attachment (Lampiran) :
From (Mulai) Until (Hingga)
Date Requested (Tanggal Diminta) :

B. TECHNICAL CONCERN (PERTIMBANGAN TEKNIS)

Precautions against damaging underground, surface and overhead facilities (Peringatan bahaya
untuk kerusakan fasilitas bawah, permukaan, dan di atas tanah):

Name (Nama) Signature (Tanda Tangan) Date (Tanggal)

Mechanical Engineer
Electrical Engineer

C. EXECUTION & PERMIT CONCERN (PERTIMBANGAN Eksekusi & Izin)

The execution may proceed, subject to the above precautions and obtaining work permit (Pekerjaan
boleh dilaksanakan, dengan mematuhi peringatan di atas dan mendapatkan izin kerja).
Name (Nama) Signature (Tanda Tangan) Date (Tanggal)
Performing Authority
Area Authority
Site Controller (SC)

THIS IS NOT A PERMIT TO WORK (LEMBAR INI BUKAN IZIN KERJA)