PEMBERtTAHUAN PEMASUKANBAnANa/ ' ..

L TEMPAT LAIN mAM DAERAH PABEANKE

' BC 4.0
hEADER
MaIn al Ppnga}urin &
Q5ad4QQQ07s1 2Q24952QOOh4
2D
A I<ANTOR PABEAN I<PPBC TMPMERAK F Kai OMKHUSUSBEADAN CUKAI
B JENIS TPB KAWASANBERIKAT Nom or PencJ8ft&ran 617iBe
C JEntIS TRAtJSAKSI PENYERAHANB1(P TangOal 20-05-2024

D DATA PEMt3[RITAHUAN

PE}K;IRIUBAnANa
,. tJF’VvF: n r1 +
/ n
++•ip I IJ +
n p
n \C 1b#
1 + !1 1
: J
: Ill -.-;}’' ' !$;J_J+.'gj ;}:- .I.:' :
f+

Jp tlarla tIt Kola.ASOL 14;LN III 6. NaI-la '' .. : Fl. IAN(j Mt)tIL WIlt A
3. AarP'at : JAI/\N HAYA SLH4\flUKM. fl. OLEA NHbAX.
1 KEL AWAIAN 7. AaFa : JEB RAYA StH/WG NU, R 1, t/Jl RW ual KEL,bl i UNO JAY A
Kl8IN. KAOJPATENSEPANG. BPNTEN KECo Q I<UPA KAB,TAt+GERAN C , BJWTEN

4. No izh TPS : KM.I09WBC.07/2022

PEtIt1 .K BA.RAIl{-i

8. NPWP : 0138623)5401(.DO
9. Nana : NIKOMASGEMILANG
IO. Aorta : JAL AN RAy A SER.416KM. 71. DESA TN#&4K. XECWAtAN Hat(
KH3UPAtLR SLR ANG.bAllIbtJ

DOt<IAdEN PCLENGKAP PA BEAN

Il PackIng t_tsr TIaD,’u37/V/2024 RF-;t;=f;i;2i 14:naIcinlit;aTF;;RBI
12 t<Dntrak !J35/SPJ8fTIAD/V /2024 Tgt 20.05,2024 fIg
13 GakrtH Pajak Tgl IS Je11tS / lv31uor /tanqgal dokurnen
Uang BatIk 8
Tgl

DA TA PEIQGANGt<UTAN

IU Jenls Sar9na Penqan9kul DARAI / PI( JK t:a '_l. NaP' I IsI A 8965 /F

DATA PERDAGANGA N

18 H argo PerWerahan 54 93600000 2D fINaI 'JaII]' IT}IIL t

030
le Nllnl PonggantlanJa8a/NHal 0.00 21 J$nIe Jae a Kelta

DATA PEFJGEMAS
22 Jenls Kemasan PACKAGE 24 Jllml€fr Kernas an 30
al Mtllok
DATA BAnANa

24 VOluml-' I'iII +1 ti U-J:.;i - 25 BeTal KCltOr 1378500 76 gIEgMj®l,Ify=1 16 /say

m El If;
b&; Uralan junllah dan }ents bar ang secara lenBkap, kotle lrarang, - Jurnldr & ienls saruan • Hwga penyDrallan (Ftp)
melt. tlpe, ukuran, dan $pesHlk&sI IaIn - BerN Bcrsllr(Kg) NfU Penggantian/ NItaIJasa
Volume (nI 3}

-–––-––- ---–-–---–––––--- 22 HIB baaW

PHII [ TANDA TANGAN PENGUSAHA TPO

IF-Fmi5iinall Rp:aT t)engan int sayamenyatakan benanggung }awaD alas keDenaram
:n . pmi Dhebaskar Rp. a.CD yarlg dtbrrhahukan dalam pcmbenrahuan paIlearl Int
38. PEll THilk HP.t\LK2.yOU.UU
8. UtflU}{PEJA8AI' BEADANCIJKAI

Nama
NtP

Rarqkal, ke.1 / 2 ; 3 . Kar,tor Raman i P9nqt8arn PB I Perqlnrn Barar9

 BC 4.0 LEMBAR LAK]UTAN
QATA BARANG

HEADER
Narn or Pellg8luan 05C34400D07S
12024052000&120 'Vb &I

A KANTOR PABEAN KPP8C TMP MERAK F Kal aM:fF

8 JENIS TPD KAWASAN BERIKA T NomOlPendaftar8n 617180
C JENISTRANSAKSI PENYERAHAN BKP TarIOyal 20.05.2024

27 28 Fly rf
NI) Uralan }urntah dan }ents bar ang sccara longkap, Rode bar ang, . Jumlall & Jenls Saruan Margo p8nyorehan (RP)
m$rk epo, ukb#on.danspo$1ftha9t laIn ' BornBers}h (Kg) NII al Pelrqg81Xlan/ NH81J8sa
- VoR#TIe (m3)

1 . Pus latIf/HS BSt:;SLl9CIO 2.(XJOO 6. 700. CDa. OO

- K(xk 8wang ZDOOoaotx>13331 SEr(SET) -0

BAN FORKLIFT 28)(9.15 (INNER TYRE + OUTER TYPE + FLAP 20 0000
TYRE) RUBBER, BRIDGESTONE Merk -.Tlpe ’ ukUfBn
SpesKlkasl laIn - 00000
2 Pos TalK/HS 84219999 475.030 OO
I .DOGg
FeE (Pt(E)
-- FUEL
I<ode FILIER
B8rang 23390
GOCXn000W9755 a
locial 71 TOYOTA, MeR ., W+ -,uklxan. - 0500G
-. Spc$Htka31 lain - 00000
3 Pos Taat#IS 84219899 1 aooo 550.000 OO

- Koch Barang <3aoaoDOol04926 PCt(PaLT) a

- Ain FiLTER 17743.236CD,71TOYOTA. Mort\ -, T7po - UktRan .
SpestflkasI IaIn- a 5500
a aLloa

4 Pos TalK/US 8S051900 2 0000 4 ,876.000 OO

I<ode Belong 20000000013332
BAN FORKLiFr O 50-10 (INNER TYRE+OLrrER TYRE+FLAP SET (STT) .0
' 20.0000
TYRE) RUBBER BRIDGESTONE, Mark -,Tlpe -, Ukwan 0 0000
Spestftkasi kin
5 - pos TMtt/HS 84878000 1 GOOD . 160.000,00

Kodo B8fang GWOOOOW43918 POEPIECE) 0

OILFILTER 15601,7600+71 TOYOTA, Mark -, TW: -, Ukwdn O 50QO
Speslflkasl laIn - 0.0000

6 . Pos TaNf/HS 84839099 8 0000 1.032.000.DO

-- Katie
GEARBar ang
OIL ZCXXX3000019626
IL SAE 140 APIGL/MT-1. FORMULA TDPI Merk'’, LTR (LITRE ( lmS
70000
)) 0

Tlpe '. Ukuran- SpastfHasl laIn . 00000

7 . Pos Tartf/HS 8505]goa 20000 404.000 00

. Kode BarNlg ' 200C>000CX>17470 PCE(PIECt:) 0
- HEAVY DUTY DIESEL ENGINE OIL ql/CAN . SAE J6W. ac' 7mac
MEOITRAN SX Melt ., TIP -, Ukuran. SpesHlkad laIn . . o.aa)o

B pos Tarf/HS 84839008 8®OO . 560,00000

. I<ode Barony zoooooao018477 I. TR (I.rrRF { : DMS )) -0
GEAROILSAE90 GL-5/MT-1 FORMULA TOP1 Melt -. TIn 7 OC>00
Ukw&n ., Sp8slflkast laIn 0 0000

9 . pos Tanf/HS 85051900 6 O000 - 72.000.00

- Koch Bar&IB DOW000002 NnI
. AIR ACCU IL, ACCU ZUUR, MURNI FORMULA. Mark -. We
POE(PEer) .0
3 0000
LAIxan -, SpesKkasl laIn- 0 0000
10 pos TaltfAIS 40161Ct90 2.0000 . 6.700.00000

- Katie Barang 200000uOC>13331 SET (SETI .0

- BANFORKLIFT 28X9.15 (INNER TYRE + OUTER WRE + FLAP 20000C;
TYRE) RUBBER. BRIDGESTONE , Men. -, TIpe , UKuran. '. 00000
SpesHlknsl laIn -
160.000 aa
11 - posTanf/HS&4879aoa - 1 DODO
KatIe Balang GOOOOCXXX143918
. OILFILTER 15601-7ao09-71 TOYOTAMerk -, TIlre -, ukrzan; PCE(PECE) a

SpesKlhnsl laIn - I- o.soDa

I- o.0000

. 480.000 OO
12 . posTntf/HS 630S1900 I . DODD
Kode Baranfl ZC>WOOOOC>20280 PL (FAIL) 0
HEAVY DUIY DIESEL ENGINE OIL IOLaAIL, SAEi5W40 F- 9,0000
MEDITRAN SX MeN - npa ' Ukurdn - Sp8slflkasl laIn, a 0000
 LEMBAR LAK]UTAN
BC 4.0 QATA BARANG

HEADER
F&naI
Narnor Peng&lu3rl as CU4000075120240520QO&120

A KANTOR PA8EAN KPPBC TMP MERAK T-T@aR}+USUSjbFA DANCUt<AI

B J€NIS TPD KAWASAN 8ERIKAT Nornor Pelrd&ttaran 617180
C JENIS TRAfVSAKSI PENYERAHAN BKP TWWgal 20.03-2024

FU B2 29 30
IJralan jumIdl dan }arIs barang 3ecara knOXV, Rode barony, HorDe p8rVwahan (RP)
NO - Jumlah& Jent3$aruan
mort. tIp$. ukwan. dan$posHtka91 laIn - BeretBers#1 (Kg) . NIM P8n99an0atV NIt&lJ&sa
, Volume (rn:3)

13 - Pas Tafl':/ttS 84219999 1.0000 1.464.000.00

- FORKLIFT
KQde BHanO GOOOOOOO112495 POE{PECE) 0
HYDRAULIC FILTER 87501- 23001.71. Mefk ,T)W . - O 5000
Ukuran,, Speslflkast laIn 0 0000

14 Pos Twlf/HS 811379)oa 30 DOGG . 1.200.000.00

Kode Barangall
' HYDRAULIC ZOOOOa)0018615
AW40 UPIDN, APN, Mort- -,Tlpe ', Ukuran' '. LTP WE
290000
( I DI-aD .0
8p$8tflk881 laIn' 00000
15 ' Pos TafF/HS &1219889 1 0000 475.000,DO

Koch BararlgGOOooa<ncH9755 PCE{FEet) a

- FUEL FILTER 23390.76001-71 TOYOTA, Men -, TIFn -, LIkuan: 0 5000
.. Spesl$k8sl laIn
- a0000

16 Pas TwttAIS 81219999 1 0000 . 742.000 OO

KocHB&ana ' GO(XX)CX)0112496
. HYDRAULIC FILTER RfrURN 67502-23000- 71, Mn
POE(PIC(IE)
0 SOOO
.0
Tbc .,

Uktaul -, Spesffkasllabl - 0.0000

17 . Pas TalK/HS 39173909 1.0000 . 7.211.000.00

- Kcxh BarangGOOOOCDa121588
SELANG }NPLrr POMPA HYDRAULIC 68110- 23&40.71. Merk. -, POEpItCH 0

0 15tD
TX)e -. UkurQr} -, spesHh asI tan - . 00000
18 . Pos TaNf/HS B8138119 E. 1 0000 18.850.000.00
- Kode B&rNW GOOOODCD121589 POEP'ECE) .Q
- POMPA HYORAUtlC e7110-23040-71
SposHtknsllain
Mark -, TWO '. Ukwan - 30000
- a.amc

19 . POSTaftfAIS 73182200 E. 1 0000 1.445.000 00

• Koch B&rang OODC>OCX>Q121325 SII ( SET) 0
- SEAL KIT OBtTROL AJMK3Q-2Sa4Q. Mark -,TIjle ., Ukwan -,
Spestflkasl laIn- - 0 0300
'. 00000
20 - Pos TaNf/HS 85051900 i. 20000 - 404.00000
. Kode B&rang ZCX30000CX>17476
HEAVY DUTY DIESEL ENGINE OIL 4L/CAN. SAE 15W-40
PCEpIECE)
I- 7 0000
.0
MEDITRAN SX, Men -, TIF>e - Ukwan ..Speslflk8 sl IaIn E. ooooo
21 PosTartf/HS 84218989 ,. I.OOCD 385.000.00

KDde BMWtO GOOOOOOQI05291 PCC(PE(1) .a

FILTER OU C-1701, Merk ,,Tlf>6 , LAw&n, -, Sp+sHfk asI lah:- '. 0.5000
00000
22 - Pas TartffHS 81219999 E-1 0000 - 601.00000
- KatIe Buang c3000aoool04811
- FUEL FILTER JFC - 8B030 . J+MCO. Merk Ttpe-, Ukuran- POE{PECE) a
Spo$tflkasl laIn' I. D 5000
- 0.0000

E TANDA TANGANPENGUSAHA TPB

' at: ,waskebenal arl haI- hd
Den(}all hi s8ya merV ataXon
yang d&rerttalwkarl adam peml 1'PT.'RIKOKAS
SERAN' 14 . 14
EN SEWQWAII
BP

LEMBAR LAhUUTAN
BC 4.0 DOKUMEN PELENGKAP PABEAN

HEADED

Narn or Pengajuan QS04400CX3

75]2024052QOQ5420

A KANTOR PABEAN KPP8CTMPMERAk F KOLOM KHUSUS BEADANCU<Al

B JENISTPB KAWAS AN BERIKAT Nom Of P8ndafwan 617188

C JENfS TRANSAKSI PENYERAHAF4 BKP THlggal 2D-05-2024

NO JENS DOKLBIEN Ne)NOR TANQQAI.

I !)aVWI INVfruy1?6w2a24 ao,ab?874

2 PACKING LIST Tnn31FVt2Q24 20.0&2024

3 K(ArRAK c3§NPJ&Th4nv/202.1
4 DELIVERY ORDER WTWR3f:IB21?324

E TANDA TANGANPENGUSAHA TPS

Deng an Rtl soya meny8tak arl bert6ngtJi;;a lawab alas kobenar arl hal-haI
yang clttnrt18hukarl dtaam pemtndtahuan pd3ean InI

DOKUMEN
LENGKAP
Tgl Oleh