S.H.E.

CLEARANCE FORM
REQUIREMENTS TO GET WW ID BADGE

To work at WW area, must FIT & pass SHE induction. Utk bekerja di WW harus sehat dan lulus SHE induction.
Company Name PT. Prima Jaya senotosa Energy Company phone no. +62 21 7889 0161 Working Area Wayang Windu Field

Contractor supervisor Angga Dwi Putranto Cont. spv phone no. +62 81220523779 Type of Work Heavy Equipment Service and Rental
Contractor to fill & submit this form to WW medic 3 days prior induction, attachments copy of: health certificate (MCU), identification card & competency certificate.
Kontraktor mengisi & mengirim form ini ke WW medic 3 hari sebelum induksi, disertai copy lampiran: surat sehat (MCU), tanda pengenal, & sertifikat kompetensi.

The contract will utilize operational vehicle. Kontrak ini akan memakai kendaraan operasional. (Vehicle shall inspect by WW SHE, driver must pass WW SIM).
The contract will require additional local manpower. Kontrak ini akan membutuhkan tambahan pekerja lokal. (Coordinate with ER team)

Work Competency Induction

No Name Job Position Signature* Induction result# MCU result#
Duration Certificate date*
1 Yoga Yogaswara Wijaya Field Mechanic 1 Year 1 1 1 FIT
2 2 2 2
3 3 3 3
4 4 4 4
5 5 5 5
6 6 6 6
7 7 7 7
8 8 8 8
9 9 9 9

Saya sudah menerima penjelasan Aturan Kerja di WW, saya mengerti dan akan mematuhi selama bekerja di Wayang Windu area.
Jika kedapatan saya melanggar aturan kerja WW, saya bersedia ditegur & menerima konsekuensi sesuai aturan yg berlaku.
Hereby, I have received explanation of WW Work Rules; I am understood and will abide by while working in the Wayang Windu area.
If caught violating the WW rules, I am willing to be remind and receive all the consequences according applicable rules.

Contractor Spv WW/SE Contract Spv Inducted by SHE Representative Remarks:

Angga Dwi Putranto Hendro Tri Yulianto

Notes: * to fill during SHE induction; # to fill by WW SHE team; SHE induction material refer to ‘SPE.WR.101c General SHE Rules.doc’
To work at WW area, must FIT & pass SHE induction. Utk bekerja di WW harus sehat dan lulus SHE induction.

WWMS Form: SPE.WR.101a Page 1 of 1 Print Date: 29 June 2024