Project No. : 080/GTU.
PIM/SP/VII/2024 REV
DOC. NO. :
FIELD INSPECTION AND TEST PLAN FOR CIVIL Date : October 22,2024
Prepared Approved
RH DNL
H : Hold Point A : Document Approval P : Perform / Prepare
W : Witness based on RFI R : Document Review Company : PT. PUPUK ISKANDAR MUDA
SW : Spot/Random Witness V : Document / Data Verification TOC : PT. GEARINDO TIGA UTAMA
F : Inspection During FAT I : Inspection
RESPONSIBILITY
METHOD OF LEVEL OF ACCEPTANCE VERIFYING
No. INSPECTION ACTIVITY/TEST ITEM REMARK
INSPECTION / REFERENCE DOCUMENT
CONTRACTOR COMPANY
1 MATERIAL
1.1 Material Submit :
Comply with Project
a. Concrete Inspect Laboratory Report I V&A
Specification
Comply with Project
b. Job Mix Design and Trial Mix Inspect Laboratory Report I V&A
Specification
Comply with Project Laboratory Report /
c. Rebar Certificate I V&A
Specification Mill Certificate
Comply with Project Visual & Dimention
f. Welding Material (Type,size,SMAW) Review I V&A
Specification Report
1.2 Test
Comply with Project
c. Welder Performance Qualification Test (WPQT) Test WPQT Report P W
Specification
Comply with Project
d. Welder Certificate Review Welder Certificate R V&R
Specification
Comply with Project
e Tensile Test & Bend Test Test for Rebar 19mm Review Test Certificate R V&R
Specification
Comply with Project
e. Slump Test Inspect QC-S-08 I V&A
Specification
Comply with Project
f. Compressive Strength Test Inspect QC-S-09 I V&A
Specification
2 FABRICATION
Comply with Project
2.1 Material Identification and Dimensional Check Inspect QC-S-05 / QC-S-06 I V&A
Specification
Comply with Project
2.2 Cutting / Bending Rebar Inspection Inspect QC-S-06 I SW
Specification
Comply with Project
2.3 Support Tray Fabrication Inspect QC-S-03 I SW
Specification
Comply with Project
2.4 Dimensional Inspection Inspect QC-S-05 / QC-S-06 I SW
Specification
3 SITE PREPARATION
3.2 Survey, Elevation, Leveling and Coordinat Inspect Comply with Spec. QC-S-01 I V&A
Comply with Spec.,
3.3 Stake Out Inspect QC-S-01 I SW
AFC drawing
4 INSTALLATION AND TEST
Dimensional, Leveling, Verticality and etc of inspection Comply with Spec.,
4.1 Inspect QC-S-01 / QC-S-06 I SW
after rebar installation AFC drawing
Comply with Spec.,
4.2 Compacted soil Inspect QC-S-02 I SW
AFC drawing
Comply with Spec.,
4.3 Leveling Concrete Inspect QC-S-04 I SW
AFC drawing
Comply with Project
4.4 Alignment and Placement Anchort Inspect QA.QC-01 I SW
Specification
4.5 WELDING INSPECTION
Comply with Spec.,
a. Visual 100 % Inspect QA.QC-03 I SW
drawing
5 CONCRETE WORK
Form work dimensi, elevation, levelling, thickness, Comply with Project
5.1 Inspect QC-S-01/QC-S-07 I SW
flatness and smooth surface of levelling Specification
Comply with Project
5.2 Rebar Installation Inspect QC-S-06 I SW
Specification
Comply with Project
5.3 Formwork Installation Inspect QC-S-07 I SW
Specification
Comply with Project
5.4 Pit Cable Excavation Inspect QC-S-10 I SW
Specification
Comply with Project
5.5 Pit Cable Back Fill Inspect QC-S-11 I SW
Specification
Comply with Project
5.6 Pit Cable Cover Inspect QC-S-12 I SW
Specification
Comply with Project
5.7 Pouring Concrete Inspect QC-S-08 I SW
Specification
PEMBANGUNAN TANGKI AMMONIA
ACEH UTARA - INDONESIA
PT. PUPUK ISKANDAR MUDA
SURVEY REPORT
Project Title : Date :
Work Title : Report No. :
Main Contractor : Page : 1 0f 3
Project Owner :
:
REFERENCES :
Item Name : Location :
Drawing No. : Revision :
Coordinate Design Coordinate Actual Different
No. DESCRIPTION Remarks
East Nort East Nort E (mm) N (mm)
Contractor Owner
Prepared & Inspected by, Witness & Approved by,
Date : Date : Date : Date :
Date :
QC-S-01
PEMBANGUNAN TANGKI AMMONIA
ACEH UTARA - INDONESIA Report No. :
Job. No. :
Subject : LEVELING REPORT (TOP GALIAN PONDASI TRANSFORMER 5000 Kva & 150 KVa)
Location/Area :
Owner :
Contractor :
Ref. Drawing :
Page. : 2 of 3
HI B-S F-S ELEVATION ELEVATION Dev.
No. DESCRIPTION REMARK
(mm) (mm) (mm) BM, CP/TP Design Actual (mm)
Contractor OWNER
Prepared & Inspected by, Witness & Approved By,
Date: Date: Date: Date:
PEMBANGUNAN TANGKI AMMONIA
ACEH UTARA - INDONESIA
PT. PUPUK ISKANDAR MUDA
SURVEY REPORT
Project Title : Date :
Work Title : Report No. :
Main Contractor : Page :
Project Owner :
Drawing No. :
Sketsa :
Contractor Owner
Prepared & Inspected by, Witness & Approved by,
Date : Date : Date : Date :
QC - S - 002
Report No.
PEMBANGUNAN TANGKI AMMONIA
NH3T-PIM-GTU-E&I-XI-CP-01
Date : November 1,2024
COMPACTION INSPECTION REPORT Project No. : 080/GTU.PIM/SP/VII/2024
Description : Compaction Inspection Report for Transformer 5000 kVA Foudation
Client : PT. PUPUK ISKANDAR MUDA
Contractor : PT. GEARINDO TIGA UTAMA
Location : NH3T TANK
REFERENCES
Drawing No. : P2-6442-T2-DW-64FB2002.4-3001-R-IFA
Revision :-
Sheet : 1 of 1
RESULT ACCEPT
NO INSPECTION ITEMS REMARKS
Accepted Rejected Cont. Owner
1 Fill material quality
2 Area location marking for layer thickness
3 Soil spreading methods
4 Thickness of loose soil
5 Water spreading methods
6 Optimum water content
7 Compactor trip number
EQUIPMENT
Total Unit : pc(s)
Sheep Foot Compactors Running Unit : pc(s) Water Source Check
Stand Unit : pc(s) Accepted Rejected
Total Unit : pc(s)
Water Quantity Due
Vibratory Compactors Running Unit : pc(s) to Wet Compaction
Check
Stand Unit : pc(s) Accepted Rejected
COMMENT
Prepared / Inspected by, Witnessed / Reviewed by, Acknowledge by,
PT. GEARINDO TIGA UTAMA PT. GEARINDO TIGA UTAMA PT. PUPUK ISKANDAR MUDA
Name : Name : Name :
Date : Date : Date :
QC-S-003
PEMBANGUNAN TANGKI AMMONIA Report No.
NH3T/PIM/GTU/E&I/XI/STF/01
Date : November 21, 2024
VISUAL / DIMENTIONAL INSPECTION REPORT Project No
(Support Tray Fabrication/Welding Work) 080/GTU.PIM/SP/VII/2024
Drawing No. : P2-6442-T2-LD-64FB2002.4-1003-R-IFA Location : NH3T
Description : Inspection for Support Tray Fabrication Sheet : 1 of 1
Inspection Date : November 22, 2024
Electrode Consumable
Result
Type of Welder Root Hot Capping
Weld No. WPS No. Size Date Weld Alignment Remarks
connection Stamp
Diameter Manufacture Specification Diameter Manufacture Specification Diameter Manufacture Specification Pass Faill
Prepared / Inspected by, Reviewed by, Acknowledge by,
PT. GEARINDO TIGA UTAMA PT. GEARINDO TIGA UTAMA PT PUPUK ISKANDAR MUDA
Name : Name : Name :
Date : Date : Date :
QC-S-004
Date : Nov. 1,2024
PEMBANGUNAN TANGKI AMMONIA Report No. :
NH3T/PIM/GTU/E&I/XI/LC/01
Project No :
LEVELING CONCRETE INSPECTION REPORT
080/GTU.PIM/SP/VII/2024
Description :
Inspection Date :
Location :
Reference Drawing :
RESULT SIGN
NO ITEM TO CHECK
YES N/A Cont. Owner
1 Quality of Material
2 Surface Preparation
3 Proportioning & Mixing
4 Elevation, extent, thickness & Surface
5 Smoothness
6 Cleaning
Remarks :
Prepared / Inspected by, Witnessed / Reviewed by, Acknowledge by,
PT. GEARINDO TIGA UTAMA PT PUPUK ISKANDAR MUDA PT PUPUK ISKANDAR MUDA
Name : Name : Name :
Date : Date : Date :
QC-S-005
Doc. No.
PEMBANGUNAN TANGKI AMMONIA
NH3T/PIM/GTU/E&I/X/FW/01
Date :
Project No.
Subject : FORM WORK INSTALATION
080/GTU.PIM/SP/VII/2024
Location/Area : NH3T Area
Owner : PT. Pupuk Iskandar Muda
Contractor : PT. Gearindo Tiga Utama
Ref. Drawing : P2-6442-T2-DW-64FB2002.4-3001-R-IFA
Name Of Type : Transformer NER Foundation 150 kVA
RESULT SIGN
No ITEM TO CHECK REMAKS
YES N/A Cont. Owner
1 Dimention
2 Tickhness Form Work
3 Leght,Widht ( Reference To Dwg)
4 Elevation, extent, & Surface
5 Smoothness
6 Qualty
7 Form Work Support
8 Cleaning
NOTE :
Prepared / Inspected by, Reviewed by, Acknowledge by,
PT. GEARINDO TIGA UTAMA PT. GEARINDO TIGA UTAMA PT PUPUK ISKANDAR MUDA
QC-S-006
Doc. No.
PEMBANGUNAN TANGKI AMONIA
NH3T/PIM/GTU/E&I/X/RI/001
Date: October 25, 2024
Subject : REBAR INSTALLATION Project No.
Project Title : PEMBANGUNAN TANGKI AMMONIA 080/GTU.PIM/SP/VII/2024
Description : Rebar Installation for Transformer Foundation 150 kVA
Location/Area : NH3 TANK / MSB
Owner : PT. PUPUK ISKANDAR MUDA
Reference Drawing : Drawing for Transformer NER Foundation 150 kVA
RESULT ACCEPTED
No. INSPECTION REMARKS
YES NO N/A DATE SIGN
1 Size/Length/Quality
2 Bending Radius/Shape
3 Spacing Between Re-bars
4 Lap Splacing (Length/Location)
5 Extra Length
6 Hook (Extra Length/Shape)
7 Hoop/Stirrup (Shape/Location/Pitch/Hook)
8 Starter Bar (Shape/Length/Location)
9 Concrete Cover
10 Slab (Direction/&Lower)
11 Reinforcing for Opening
12 Column/Beam (Untorsionality)
13 Quality of Cleaning
14 Adequacy of Spacer Block, Steel Chairs, Steel Spacer, etc.
15 Dewatering
NOTE :
Prepared / Inspected by, Reviewed by, Acknowledge by,
PT. GEARINDO TIGA UTAMA PT. GEARINDO TIGA UTAMA PT. PUPUK ISKANDAR MUDA
Name : Name : Name :
Date : Date : Date :
QC-S-008
Report No :
PEMBANGUNAN TANGKI AMMONIA NH3T/PIM/GTU/E&I/XII/PC/01
Date : December 3, 2024
Project No. :
POURING CONCRETE RECORD 080/GTU.PIM/SP/VII/2024
Owner : PT. PUPUK ISKANDAR MUDA
Contractor : PT. GEARINDO TIGA UTAMA
Location : NH3T / MSB2
Concrete Class :
Specified Strength of Concrete : …………………………………Mpa ( …………psi )
Time Cylinder Slump Poured Total
Date Description / Area / Block 3
Batch Plan On Site Speciment No cm Vol. (m ) (m3)
Remarks :
Prepared / Inspected by, Reviewed by, Acknowledged,
PT GEARINDO TIGA UTAMA PT GEARINDO TIGA UTAMA PT PUPUK ISKANDAR MUDA
Name : Name : Name :
Date : Date : Date :
QC-S-009
Report No.
:
PEMBANGUNAN TANGKI AMMONIA NH3T/PIM/GTU/E&I/XI/SR/01
Date : December 3, 2024
Project No
:
COMPRESSIVE STRENGTH TEST
080/GTU.PIM/SP/VII/2024
Report No :
1. General
Date / Time : :
Design Compressive Strength : K-420 (28 days)
Mix Design No : 08/JMD-JMF/II/LB&S/TS/PNL/2024
Placing Location / Purpose :
Test Method : ASTM
2. Test Result of Concrete
1. Fresh Concrete Test
Slump : ( cm )
Air Content : (%)
0
Fresh Concrete Temperature : ( C)
0
Ambient Temperature : ( C)
Test Cylinder Number :
2. Compressive Strength Test
........ Day Strength
Specimen No. Weight Breaking Strength Strength
Test Date Result
(Kg) Load (kN) (MPa) (kg/cm²)
* Test Machine No. :
3. Test Result
Acceptable
Not Acceptable
Prepared / Inspected by, Reviewed by, Acknowledge by,
PT GEARINDO TIGA UTAMA PT GEARINDO TIGA UTAMA PT PUPUK ISKANDAR MUDA
Name : Name : Name :
Date : Date : Date :
QC-S-010
Report No. :
PEMBANGUNAN TANGKI AMMONIA
NH3T/PIM/GTU/E&I/XI/EPC/01
Date : November 28,2024
Project No :
EXCAVATION PIT CABLE INSPECTION REPORT
080/GTU.PIM/SP/VII/2024
Description : Transformer 150kVA PIT Cable Installation
Inspection Date : November 30,2024
Location / Area : NH3 Tank / MSB2
Reference Drawing : P2-6442-T2-DW-64FB2002.4-1009-R-IFA
RESULT SIGN
NO ITEM TO CHECK
YES N/A Cont. Owner
1 Dimentional and Visual Check
2 Depth of Excavation Check
3 Condition of compaction bottom surface
4 Quality of cleaning
Remarks :
Prepared / Inspected by, Reviewed by, Acknowledge by,
PT. GEARINDO TIGA UTAMA PT. GEARINDO TIGA UTAMA PT PUPUK ISKANDAR MUDA
Name : Name : Name :
Date : Date :
QC-S-011
Report No. :
PEMBANGUNAN TANGKI AMMONIA
NH3T/PIM/GTU/E&I/XI/PCB/01
Date : December 3,2024
Project No :
PIT CABLE BRICKLAYING / BACKFILLING INSPECTION REPORT
080/GTU.PIM/SP/VII/2024
Description : Transformer 150kVA PIT Cable Bricklaying/Backfilling
Inspection Date : November 30,2024
Location / Area : NH3 Tank / MSB2
Reference Drawing : P2-6442-T2-DW-64FB2002.4-1009-R-IFA
RESULT SIGN
NO ITEM TO CHECK
YES N/A Cont. Owner
1 Quality of Material
2 Stability against brick placing
3 Alignment Surface and Wall brick
4 Surface and Alignment
5 Backfilling soil
6 Quality of cleaning
Remarks :
Prepared / Inspected by, Reviewed by, Acknowledge by,
PT. GEARINDO TIGA UTAMA PT. GEARINDO TIGA UTAMA PT PUPUK ISKANDAR MUDA
Name : Name : Name :
Date : Date : Date :
QC-S-012
Report No. :
PEMBANGUNAN TANGKI AMMONIA
NH3T/PIM/GTU/E&I/XI/PCI/01
Date : November 29,2024
Project No :
PIT CABLE COVER INSPECTION REPORT
080/GTU.PIM/SP/VII/2024
Description : Transformer 150kVA PIT Cable Cover Installation
Inspection Date : November 30,2024
Location / Area : NH3 Tank / MSB2
Reference Drawing : P2-6442-T2-DW-64FB2002.4-1009-R-IFA
RESULT SIGN
NO ITEM TO CHECK
YES N/A Cont. Owner
1 Quality of Material
2 Dimentional and Visual Check
3 Surface Check
4 Quality of cleaning
5 Stability against cover placing
Remarks :
Prepared / Inspected by, Reviewed by, Acknowledge by,
PT. GEARINDO TIGA UTAMA PT. GEARINDO TIGA UTAMA PT PUPUK ISKANDAR MUDA
Name : Name : Name :
Date : Date :
