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FM.04.LSP_rev.01.20 1 6

SURYEYOR /MPORT REPORT

I\,4INYAK BUMI, GAS AUMI, DAN BAHAN BAKAR LAIN / PFTROLEUM, NATURAL GAS AND OIHER FUELS
PERATURAN MENTERI PERDAGANGAN RI NO.O3/M-DAGFER/1/2015
REGULATION OF TRADE MINISTRY NO.O3A'.DA G/PER/1/2015

vi No. vRI03652 lO No. 1O15127018 Ls No. 15201809-4391

l. Parties Concemed
lmpo er / lmportir Exporter / Eksportii
Name / Nama PT Pertamina (Persero) Name / Nama : Total Trading Asia Pte. Ltd.
Address / Alamat Jl. Medan Merdeka Timur No. 1A, Address / Alamat : 250 North Bridge Road, #39-00
Kel. Gambir, Kec. Gambir Jakarta City Tower, Singaporo '179101
Pusat
Country / Negara lndonasia Gountry / Negara : Singapore
NPWP 010016640051000
API/APIT No 090203958-P
SPI No 04.Pt-63.18.0037
Expiry / Berlaku s.d. 311121201a

ll. Shipment Deta / Data Pengiriman

Mode of Transportation / :Sea lnvoice No. : SPS12637
Moda Transportasi
Vessel/AircBfr (Nama Alat : MT. Great Sailor lnvoice Date / Tanggal :04/09/2018
Angkut) InvoiGe
Voyage No. / No. :-
Pengiriman
Country of Origin / Negara : Singapore LC Dat€ / Tanggal LC:
Asal
Port of Loading / : Singapore BUDoc No : 138638/DS 1/l.2
Pelabuhan Muat
Port of Discharge / rKotabaru BL /Doc Dat€ / Tanggal ; 03i09/2018
Pelabuhan Bongkar BL
Place of lnspection / : Singapore Date of lnspection / ;03/09/2018
Tempat Pemeriksaan Tanggal Pemeriksaan

lll. Details of Goods lnspected / Rincian Balang

No HS Code / Kode HS Description of Goods / Keterangan Barang Quantity/Unit
Weiqht I Berat Volume
,|
27101224 Gasoline 92 RON Unleaded 3477 .276 MT 299M.000 USB

Date of lssued / Tanggal Terbit :04i09i2018

Penerbit:Jakarta

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