Form Instrument Rev 1

Date :
QI - J01
JASA PERANCANGAN PENGADAAN DAN KONSTRUKSI
PEMBANGUNAN PIPA TRANSMISI GAS DARI
Doc. No. : Page :
GRESIK - SEMARANG
of
INSTRUMENT CABLE INSULATION RESISTANCE AND CONTINUITY TEST RECORD AFTER
INSTALLATION Project No. :
Client : Project Title :
Location / Area : …………………………………… Serial No. : ……………………………………

Test Equipment Used : …………………………………… Calibration Expery date : ……………………………………
Insulation Tester Volt. : ………..Volt DC Calibration ID No. : ……………………………………
Cable Spect & Size : …………………………………… Drawing No. & Rev. : ……………………………………
Field Instrument. Junction Box
JB Tag No. :
From Field Instrument Cable Specification To Junction Box

Insulation
No. Terminal Terminal
Tag.No. Wire Color Cable Spect, Size & Lenght. Wire Color To Wire Color Resistance (MW)
No. Block No.
* CONTINUITY TEST PASSED : YES NO

INSULATION TEST : BETWEEN SHIELD TO SHIELD MW
BETWEEN SHIELD TO ARMOURED MW ( if any )
* NOTE : …………………………………………………………………………………………………………………………….
…………………………………………………………………………………………………………………………….
…………………………………………………………………………………………………………………………….
Prepared by : : Review/Witness/Approved by : :
Konsorsium Wika Rabana Kelsri PMC/PT Pertamina Gas
QC Representative/QC
Name : Name :
Sign : Sign :
Date : Date :
Date :
QI - J01a
PEMBANGUNAN PIPA TRANSMISI GAS DARI Doc No. : Page :
GRESIK - SEMARANG
of
INSTRUMENT CABLE INSULATION RESISTANCE AND CONTINUITY TEST RECORD
AFTER INSTALLATION
Project No. :
Location / Area : …………………………….. Insulation Tester Volt : ……………………………

Test Equipment Used : …………………………….. Calibration Expery date : …………… Volt. DC
Serial No. : …………………………….. Calibration ID No. : ……………………………
Drawing No. & rev. : …………………………….. : ……………………………
Cable Specification
Cable Tag No. Cable Specification
From and Size
To Length .meters
(A) INSULATION TEST : BETWEEN EACH CORE TO GROUND / ARMOUR (MEGA OHMS)
(B) INSULATION TEST : BETWEEN EACH CORE TO SHIELD (MEGA OHMS)
Core 1 2 3 4 5 6 7 8 9 10
(A)
(B)
Core 11 12 13 14 15 16 17 18 19 20
(A)
(B)
Core 21 22 23 24 25 26 27 28 29 30
(A)
(B)
Core 31 32 33 34 35 36 37 38 39 40
(A)
(B)
INSULATION TEST : BETWEEN SHIELD / ARMOUR MW ( Average )
INSULATION TEST : CORE TO CORE MW ( Average )

( Detail Record see Attachment, if any )
CONTINUITY TEST PASSED : YES NO
NOTE :
Name : Name :
Sign : Sign :
Date : Date :
Cable No. : ………………………………………………………………
Doc No. : Date :
JASA PERANCANGAN PENGADAAN DAN KONSTRUKSI ATTACHMENT
GRESIK - SEMARANG QI - J01a
Cable Specification : ……………………………………………………………..
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
Name : Name :
Sign : Sign :
Date : Date :
Date :
JASA PERANCANGAN PENGADAAN DAN KONSTRUKSI QI - J02
PEMBANGUNAN PIPA TRANSMISI GAS DARI Doc. No. : Page :
GRESIK - SEMARANG of
TEST REPORT OF INSTRUMENT PRESSURE PIPING / TUBING Project No. :
Location : ……………………………………………………… Test Equipment Used : …………………………………………………………

Area : ……………………………………………………… : …………………………………………………………
Drawing No. & rev. : ……………………………………………………… : …………………………………………………………
Visual Inspection Hydro Test Pneumatic Test
Press. Rating
Instrument
Measuring
Operating
Range of
(Kg/cm2)
Upstream &
Test Press.
Test Press.
Downstrea
Result
Material &
Press.
Test Fluid
Test Fluid
(Kg/cm2)
(Kg/cm2)
Support
NO. Tag No. REMARKS
Rating
Result
Slope
m
Date Sign
Note :
Name : Name :
Sign : Sign :
Date : Date :
Date :
QI - J03
GRESIK - SEMARANG
Doc. No. : Page :
of
TEST REPORT OF INSTRUMENT AIR SUPPLY PIPING Project No. :
Location / Area : …………………………… Drawing No. & rev : ……………………………..
Branch / Header No. : …………………………… : ……………………………..
RESULT ACCEPTED
NO. TAG NO. REMARKS
LEAK BLOW DATE SIGN
NOTE :
Name : Name :
Sign : Sign :
Date : Date :
Date :
QI - J04
GRESIK - SEMARANG Doc. No. : Page :
of
INSTRUMENT CALIBRATION RECORD Project No.:
Tag. No. :
Type : Serial No. : Accuracy :

Manufacture : Service : Data Sheet :
Range : Type/Model : Location :
Scale Range : Output : Amb. Temp :
Calibration Check (Before)

Input Output (rising input signal) Output (falling input signal)
% of Span Actual Actual Scale range % of Deviation Actual Scale range % of Deviation
0
25
50
75
100
Calibration Check (After)

% of Span Actual Actual Scale range % of Deviation Actual Scale range % of Deviation
0
25
50
75
100
CALIBRATOR EQUIPMENT TEST

Test Equipment used : :
( w/ Accuracy)
: :
: :
Setting : [ ] direct [ ] reverse

Alarm settings : H : L :
HH : LL :
Range of automatic temperature correction :

Selected correction for spec. gravity or density :
Failure of auxiliary energy [ ] to max. scale deflection [ ] to min. scale deflection

Failure of input signal [ ] to max. scale deflection [ ] to min. scale deflection
Conform to specification [ ] yes [ ] no
NOTE :
Name : Name :
Sign : Sign :
Date : Date :
Date :
QI - J05
Doc. No. : Page :
GRESIK - SEMARANG
of
CONTROL VALVE CALIBRATION / STROKE TEST REPORT Project No.:
Client : Project title :
: …………...………………...…… AREA : …………...………………...…………………
Tag. No. :
Location / Area : Service :
Size & Rating : Serial No. :
Manufacture : Output :
Type No. : Dwg No. & rev. :
Range : Spect/ Data sheet No. :
Scale Range : :
CALIBRATION CHECK
Degree of Input Valve

% of Output Valve Position Control Valve Position ON/OFF
Control Positioner Position Switch
Span Positioner ( Panel View ) Valve
Valve PID ( % )
25
50
75
100
75
50
25
REFERENCE
Type of Valve : Control Valve ON / OFF Valve
Open Time : ……….. Sec. Conforms to Specification : YES NO N/A
Closing Time : ……….. Sec. Conforms to Specification : YES NO N/A
Failur of Auxiliary Enegy : to maximum (opened) to minimum (closed) Freeze.

Failur of Input Signal : to maximum (opened) to minimum (closed) Freeze.
NOTE : …………………………………………………………………………………………………………………………………………..
…………………………………………………………………………………………………………………………………………..
…………………………………………………………………………………………………………………………………………..
Name : Name :
Sign : Sign :
Date : Date :
Date :
QI - J06
of
INTEGRAL LOOP FUNCTION TEST DCS RECORD Project No.:
LOOP No. :
LOOP DIAGRAM No. : …………...…………………… rev. :…….. AREA/LOCATION : …………...………………...……………
Analog Input (DCS/ESD) Measuring Scale Range Simulated Local DCS / ESD
Tag No. : Range (Unit) ( Unit ) Input Indicator Reading
W/Calibration Test used :

……………………………
……………………………
Alarm / Trip (ESD) Setting Result Alarm / Trip (DCS) Setting Result
Tag No. : HH Tag No. : HH
H H
L L
LL LL
Digital Input (DCS/ESD) Field DCS Alarm Annunciator ESD

Tag No. : Switch
Open
Close
Control output (DCS) Control Control Valve

Tag No. : output Position (mA)
0% .mA
25% .mA
50% .mA This Valve is Air Failure / Electric Failure
75% .mA [ ] Open [ ] Close
100% .mA note : as per data sheet
On/Off Valve (DCS/ESD) On / Off Valve

Output Position (%)
Tag No. : This Valve is Air Failure / Electric Failure
Open .% [ ] Open [ ] Close
Close .% note : as per data sheet
Digital Output (DCS/ESD) Output Field DCS / ESD Local Control Panel
Tag No. : Open
Close
Graphic Display on Console : ………………………………………………………………………………………….
NOTE : ………………………………………………………………………………………………………………………………..
………………………………………………………………………………………………………………………………..
………………………………………………………………………………………………………………………………..
Name : Name :
Sign : Sign :
Date : Date :
Date :
QI - J06A
of
INTEGRAL LOOP FUNCTION TEST PLC RECORD PROJECT NO. :
LOOP No. :
LOOP DIAGRAM No. : …………...…………………. rev. :…….. AREA/LOCATION : …………...………………...……………
Analog Input Measuring Scale Range Simulated Local DCS PLC

Tag No. : Range ( Unit ) ( Unit ) Input (mA) Indicator Reading Reading
Alarm / Trip Setting Result

Tag No. : HH
H
L
LL
Field Field Indication Panel

Digital Input ( Valve ) D.I/Limit. Switch View - PLC
Tag No. : Open
Close
Control output Control Control Valve

Tag No. : output Position (%)
0% %
25% %
50% %
75% % This Valve is Air Failure
100% % [ ] Open [ ] Close
On / Off Valve On / Off Valve

Output
Tag No. : Position
Open % This Valve is Air Failure
Close % [ ] Open [ ] Close
Field Field D.O / Indication Panel Indication on

Digital Output ( Valve ) Limit. Switch View on PLC DCS
Tag No. : Open
Close
NOTE : ……………………………………………………………………………………………………………………………………..
……………………………………………………………………………………………………………………………………..
Name : Name :
Sign : Sign :
Date : Date :
Date :
QI - J07
GRESIK - SEMARANG Doc No. : Page :
of
INSPECTION REPORT FOR PANEL AND JUNCTION BOX INSTALLATION Project No. :
Location / Area : …………………………………. Equipment / Panel No. : ………………………………………
Drawing No. : …………………….. rev.: ….. Brand & Manufacture : ……………………………………...
RESULT ACCEPTED
No. INSPECTION REMARKS
YES NO N/A DATE SIGN
1. Visual and Dimensional out side Panel as per Outline
Drawing / Arangement.
2 Check Orientation & Position Panel.
3 Check internal Installation Equipment as per document.
4 Check Support installation.
5 Check Complete All Sim, Bolt, Nuts & Screw.
6 Check Removable Plate,Cable entry protection & Position.
7 Touch-Up Painting.
8 No Conflict with Other Installations.
9 Check Tag Number & Name Plate.
10 Check Cable Marking.
11 Check Tube Marking & Cable Lug.
Note :
Name : Name :
Sign : Sign :
Date : Date :
Date :
QI - J08
of
SEQUENCE TEST RECORD Project No.:
Equipment Tag No. of Sequence :
Status of Sequence :
Location / Area :
Interlock Logic Diagram No. :
Sheet No. :
Panel No. :
Result :
The Squence as per logic number have tested correctly ( see attachment drawing ).
NOTE :
Name : Name :
Sign : Sign :
Date : Date :
Date :
QI - J.09
GRESIK - SEMARANG Doc. No : Page :
of
TRANSMITTER INSTALLATION CERTIFICATION RECORD Project No.:
Instr. Type : ……………………………………… Service Line : ………………………………………….
Mfr. : ……………………………………… Output : ………………………………………….

Range : ……………………………………… Data sheet No.: ………………………………………….
Serial No. : ……………………………………… Hook-Up Dwg : ………………………………………….
Tag No. :
RESULT ACCEPTED
NO ITEM TO CHECK REMARKS
1 Tag Number is Correct
2 Description of Tag Plate Conform to Data Sheet
3 Process Connection and Material are Correct
4 Stanchion and Support Installation are Correct
5 Description Cable Marker is Correct
6 Conform with Hook-Up drawing
7 Cable Entry, Marker & Termination is Correct
8 Completely & tightening of Bolts and Nuts
9 Orientation is Correct
10 No Conflict with Other Installation
11 Touch-up & painting
12 Routing perforated tray are Correct
13 Installation Gasket is Correct (if any)
14 Insulation is Correct (other sub-cont, if any)
15 Steam Tracing is Correct (if any)
16 Easy to Maintenance Location
Reff Document : - Instrument Hook-Up Drawing - Manual Book & Vendor Drawing (if Any)
- Individual Specification or data sheet
Note :
Name : Name :
Sign : Sign :
Date : Date :
Date :
QI - J.09a
GRESIK - SEMARANG Doc. No : Page :
of
PRESSURE & TEMPERATURE GAUGE INSTALLATION CERTIFICATION RECORD Project No.:
Instr. Type : ………………………………………. Service Line : ………………………………………………

Mfr. : ………………………………………. Output : ………………………………………………
Size & Rating : ………………………………………. Data Sheet No. : ………………………………………………
Serial No. : ………………………………………. Hook-Up Dwg : ………………………………………………
Tag No. :
RESULT ACCEPTED
No. ITEM TO CHECK REMARKS
1 Tag Number
2 Conform to data sheet
3 Conform to Drawing Specification
4 Conform to P & ID Drawing
5 Process Connection and Material, Gasket are Correct
6 Check Orientation
7 Completely Bolts and Nuts
8 No Conflict with Other Installation
9 Conform to Hook-Up drawing
10 Insulation Completed (other sub-cont, if any)
11
NOTE :
Name : Name :
Sign : Sign :
Date : Date :
`
Date :
QI - J10
of
PRESSURE SAFETY VALVE TEST RECORD Project No.:
A. DATA FOR SAFETY VALVE.

1. TAG. No. :
2. DATA SHEET No. :
3. DRAWING No. :
4. LOCATION / SERVICE :
5. SERIAL No. :
6. INSTALLED ON EQUIPMENT No. :
7. EQUIPMENT DESIGN PRESSURE :
8. TYPE :
9. SIZE :
10. CAPACITY :
11. NORMAL OPERATION TEMPERATURE :
12. SETTING PRESSURE :
13. FACTOR CORRECTION :
B. TEST DATA
1. TEST MEDIUM :
2. AMBIENT TEMPERATURE :
3. ACTUAL POPPING PRESSURE / CDTP :
4. SEAT LEAK TEST :
5. BACK PRESSURE TEST :
6. RESULT :
Remarks : repair for remove Plug or re-setting
NOTE : ………………………….……………………………………………………………………………………………………………………
………………………….……………………………………………………………………………………………………………………
………………………….……………………………………………………………………………………………………………………
………………………….……………………………………………………………………………………………………………………
………………………….……………………………………………………………………………………………………………………
Name : Name :
Sign : Sign :
Date : Date :
QI - J11 Date :
of
INSTRUMENT CALIBRATION RECORD

Project No :
FOR DEFFERENTIAL PRESSURE AND SWITCH
Tag. No. :
Type : Service :
Manufacture : Output No. :
Range : Spec No. :
Span : Data Sheet :
Serial No. : Ambient Temperature : o
C.
Calibration Check
Input INCREASE Input DECREASE
Desired Actual Desired Actual

% of Span % of Deviation % of Span % of Deviation
( Calibrator ) ( Indicator ) ( Calibrator ) ( Indicator )
0 100
25 75
50 50
75 25
100 0
Test Equipment used : Test Equipment used :
Test Equipment used : Test Equipment used :
Setting : [ ] direct [ ] reverse

Alarm settings : H : L :
HH : LL :
Range of automatic temperature correction :

Selected correction for spec. gravity or density :
Failure of auxiliary energy [ ] to max. scale deflection [ ] to min. scale deflection

Failure of input signal [ ] to max. scale deflection [ ] to min. scale deflection
Conform to specification [ ] yes [ ] no
NOTE :
Name : Name :
Sign : Sign :
Date : Date :
Date :
QI - J12
of
INSPECTION FOR CABLE LADDER AND TRAY INSTALLATION Project No. :
RESULT ACCEPTED
No. INSPECTION REMARKS
1. Visual & Dimensional

2 Check Support of Cable Tray Accepted
3 Check completely of Accessories
4 Check Cable Tray of Alignment
5 Check Installation of Separator (if any)
6 Check Complete & Tightening All Bolt & Nuts
7 Check Grounding Connection
8 Check completely of cover with Clamp (if any)
9 No Conflict with Other Installations
10 …………………………………………………
11 …………………………………………………
NOTE :
Name : Name :
Sign : Sign :
Date : Date :
Date :
QI - J13
Doc. No. : Page :
GRESIK - SEMARANG
of
CONTROL VALVE INSPECTION RECORD Project No. :
TAG NO. :
Loop Tag. No. : ……………………………. Service : …………………………….. Serial No. : …………………………………
Type : ……………………………. Type No. : …………………………….. Spec. No. : …………………………………
Manufacture : ……………………………. Order No. : …………………………….. Output : …………………………………
Range : ……………………………. Span : …………………………….. : …………………………………
No. INSPECTION YES NO N/A DATE SIGN REMARKS
1. Flow Direction Conform to P & ID Drawing
2. Conform to Data Sheet
3. Conform to Specification and Drawing Control Valve
4. Bolt & Nut Dimensional and Material for Flange to Flange
5. Gasket Material for Flange to Flange
6. Air Supply pipe / Tubing Route and Support
7. Cable Tray Route and Support
8. Touch-up Paint
9. Color code
10. Cable Ties and Dressing for Cable entry
11. Power Supply
12. Cable Connection
Note :
Name : Name :
Sign : Sign :
Date : Date :
Date :
QI - J14
of
INSTRUMENT CALIBRATION RECORD FOR TEMPERATURE Project No :
Serial No. : Accuracy : +/- % (see vondor data if any)

Line / Service : Model /Type :
Range Temperature : Amb't Temperature : o
C.
Burn Out : Up Down :
type of Element : S - type N - type K - type E - type J - type RTD - type

T - type W - type B - type R - type KP - type Bimetal type
Tag. No. :
MEASURED RANGE.

deg Desired Actual Scale Range % of Actual Scale Range % of Remarks
0
C Value Ohm / Volt / mA deg. Deviation Ohm / Volt / mA deg. deviation
Configuration Data : See Attached Not Applicable (N/A)

Ohm Micro Volt mile Ampere
Calibration Equipment Test
: :
: :
We certify that the switches provided on this order have been tested and calibrated at our works
and are in and unsed condition
NOTE :
Name : Name :
Sign : Sign :
Date : Date :
Date :
QI - J15
JASA PERANCANGAN PENGADAAN DAN
KONSTRUKSI PEMBANGUNAN PIPA TRANSMISI GAS
DARI GRESIK - SEMARANG Doc. No. : Page :
of
INSTRUMENT SWITCHES TEST AND SET DATA RECORD Project No. :
Type : …………………………. Serial No. : ………………………… Accuracy : …………………………

Manufacture : …………………………. Service : ………………………… Data Sheet : …………………………
Range : …………………………. Type/Model : ………………………… Location : …………………………
Scale Range : …………………………. Output : ………………………… Amb. Temp : …………………………
TAG NO. :
Maximum Working Pressure : .kg/cm2g / Psi / Bar.
Setting range : .kg/cm2g / Psi / Bar.
Input set point Set Reset Dead Band Remarks

No
( ) ( ) ( ) ( )
( )
( )
( )
( )
( )
* Set Point should be confirmed and recorded three times.
Switch Configuration : Hig at Contact Low at Contact

Make Break
Test Medium : Inst. Air Nitrogen

Hand Pump
Test Equipment used :

( w/ Accuracy)
NOTE :
Name : Name :
Sign : Sign :
Date : Date :
Date :
Q I- J16
GRESIK - SEMARANG Doc. No. Page :
of
ANALYZER CALIBRATION RECORD Project No.
Tag No. :
Equipment : Serial No. : Spec. No. :

Manufacture : Service : Location :
Range : Type/Model : Amb. Temp :
Accuracy : Output : :
TRANSMITTER
DCV Standard OUTPUT

TB 2 - 1 Before After
Temperature
Remarks
o
C Conductivity / Conductivity /
TB 2 - 2 mA Error (%) mA Error (%)
pH / O2 / Chlorine pH / O2 / Chlorine
PROBE & TRANSMITTER
OUTPUT
Before After
BUFER SOLUTION
RANGE Remarks
STANDARD Conductivity / Conductivity /
pH / O2 / Chlorine mA Error (%) pH / O2 / Chlorine mA Error (%)
Test Equipment used

: :
w/Accuracy ( if any )
: :
: :
NOTE :
Name : Name :
Sign : Sign :
Date : Date :
Date :
QI - J17
of
INSTRUMENT PIPING & TUBING INSTALLATION RECORD Project No.:
Client : PROJECT :
Sheet No. : ……………………………………… Area/Location : ……………………………

Drawing hook-up No : ……………………………………… Unit / Facility : ……………………………
: ……………………………………… : ……………………………
RESULT ACCEPTED
No. ITEM TO CHECK REMARKS
1. Visual & Dimensional of Drawing/Hook-up type

2. Check of Support, Brace & Coloumn type
3. Check of Piping/Tubing, Fitting, Valve & Accessories
4. Check of welding & NDT ( Radiography & Penetrant Test) (see Attached if any)
5. Check of Threaded Connection & seal tape teflon
6. Check Standard Material & Class
7. Check Service, Fluid, Line number & Press. Rating
8. Check orientasion & no conflic w/other installation
9. Check of Clamp, Bolt & Nuts
10. Touch-Up Panit
11. Space allowance for thermal expansion
12. ……………………………………………………………
NOTE :
Name : Name :
Sign : Sign :
Date : Date :
Date :
QI - J18
Doc. No. : Page :
GRESIK - SEMARANG
of
CABLE LAYING ON LADDER & TRAY Project No. :
LOCATION / AREA :…………………………………… MATERIALS :……………………………………

REFERENCE DRAWING :…………………………………… MANUFACTURE :……………………………………
:…………………………………… :……………………………………
RESULT ACCEPTED
No. INSPECTION
YES NO N/A DATE SIGN REMARKS
1. Dressing Cable & Tie Wrapping Correct

2. Cable Markers Complete
3. Cable Specification Correct
4. Documentation Correct
5. Check Power & Signal Cable of Cross Section Correct
6. No Conflict with other Installation
7. Installation Cover Plate after release
8.
9.
10.
11.
NOTE :
Name : Name :
Sign : Sign :
Date : Date :
Date :
QI - J19
of
SETTING PROBE AXIAL OR VIBRATION RECORD Project No :
Tag. No. :
Model / Type : Prox Scale Factor :

Serial No. : Zero Voltage : .Vdc
Manufacture : Total Clearence : .mm
Location / Service : Accuracy : +/- % (see vondor data if any)
Amb't Temperature : :
SEETING RECORD DATA
In Action Side Action Side Location / Position

Measuring Remarks
( ) ( ) Probe
Dial .mm .mm
Voltage .Vdc .Vdc
DCS .mm .mm
Note :
Name : Name :
Sign : Sign :
Date : Date :
Date
QI - J20
GRESIK - SEMARANG Doc. No Page
of
INSPECTION OF GROUNDING SYSTEM Project No :
Location : Erection by. :

Number of electrodes : Weather :
Type of conductors : Temperature :
Type of electrodes :
Reference drawing :
RESULT ACCEPT
ITEM TO CHECK REMARKS
YES NA DATE SIGNATURE
1 Visual inspection during pulling cable
2 Check cable size and installation
3 Check underground cable jointing
4 Check construction electrodes
5 Check cable clamp and layout
6 Check protective measurement
7 Check grounding connection
8 Grounding continity test
9 Inspect resistance of each electrodes
10 Insulation resistance measurement
11
Remarks :
Name : Name :
Sign : Sign :
Date : Date :
Date
QI - J21
PEMBANGUNAN PIPA TRANSMISI GAS DARI Doc. No Page
GRESIK - SEMARANG
of
GROUNDING CONTINUITY TEST DATA Project No :
Owner : Test Instrument :_________________________

Standard : Type :_________________________
Category : Range :_________________________
Location : Serial No. :_________________________
Reference Drawing : Manufacture :_________________________
Temperature :
Weather :
Termination CONCLUSION
Equipment No. Continuity
Connection ACCEPTED/ REJECTED
REMARKS :
Name : Name :
Sign : Sign :
Date : Date :
Date
QI - J22
PEMBANGUNAN PIPA TRANSMISI GAS DARI Doc. No Page
GRESIK - SEMARANG
of
GROUNDING RESISTANCE TEST DATA Project No :
Owner : Test Instrument

Location : Type :
Reference Drawing : Range :
Temperature : Serial No. :
Weather : Manufacture :
EQUIP. NO. LOCATION/ GROUNDING CONCLUSION

GROUND ROD NO. TEST POINT RESISTANCE (Ohm) ACCEPTED/ REJECTED
REMARKS :
Name : Name :
Sign : Sign :
Date : Date :
Date
QI - J23
PEMBANGUNAN PIPA TRANSMISI GAS DARI Doc. No. Page
GRESIK - SEMARANG
of
INSULATION RESISTANCE TEST DATA FOR CONTROL CABLE Project No :
Owner : Test Instrument

Location : Type :
Reference Drawing : Range :
Temperature : Serial No. :
Weather : Manufacture :
RATING INSTALLED MEGGER TEST (M ohm) RESULT

NO. CABLE NO.
VOLTAGE FROM TO CORES TO CORES ACCEPTED REJECTED
REMARKS :
Name : Name :
Sign : Sign :
Date : Date :
Date :
JASA PERANCANGAN PENGADAAN DAN KONSTRUKSI QI - J24
PEMBANGUNAN PIPA TRANSMISI GAS DARI Doc. No. : Page :
GRESIK - SEMARANG
of
MATERIAL IDENTIFICATION RECORD Project No. :
Client : _________________________________________________ Project Title : _________________________________________________

Location : _________________________________________________
NO. DATE DESCRIPTION SIZE GRADE HEAT NO. BATCH NO. MILL CERTIFICATE SUPPLIER COLOUR EXPIRED DATE DOC NO. REMARKS
Notes :
Name : Name :
Sign : Sign :
Date : Date :

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Date :

Client : Project Title :

Location / Area : …………………………………… Serial No. : ……………………………………

Field Instrument. Junction Box

From Field Instrument Cable Specification To Junction Box

* CONTINUITY TEST PASSED : YES NO

Client : Project Title :

Location / Area : …………………………….. Insulation Tester Volt : ……………………………

INSULATION TEST : BETWEEN SHIELD / ARMOUR MW ( Average )

INSULATION TEST : CORE TO CORE MW ( Average )

TEST REPORT OF INSTRUMENT PRESSURE PIPING / TUBING Project No. :

Client : Project Title :

Location : ……………………………………………………… Test Equipment Used : …………………………………………………………

Visual Inspection Hydro Test Pneumatic Test

TEST REPORT OF INSTRUMENT AIR SUPPLY PIPING Project No. :

Client : Project Title :

Location / Area : …………………………… Drawing No. & rev : ……………………………..

Branch / Header No. : …………………………… : ……………………………..

Type : Serial No. : Accuracy :

Calibration Check (Before)

Calibration Check (After)

CALIBRATOR EQUIPMENT TEST

Setting : [ ] direct [ ] reverse

Range of automatic temperature correction :

Failure of auxiliary energy [ ] to max. scale deflection [ ] to min. scale deflection

CONTROL VALVE CALIBRATION / STROKE TEST REPORT Project No.:

Client : Project title :

: …………...………………...…… AREA : …………...………………...…………………

Degree of Input Valve

Open Time : ……….. Sec. Conforms to Specification : YES NO N/A

Closing Time : ……….. Sec. Conforms to Specification : YES NO N/A

Failur of Auxiliary Enegy : to maximum (opened) to minimum (closed) Freeze.

LOOP DIAGRAM No. : …………...…………………… rev. :…….. AREA/LOCATION : …………...………………...……………

W/Calibration Test used :

Digital Input (DCS/ESD) Field DCS Alarm Annunciator ESD

Control output (DCS) Control Control Valve

On/Off Valve (DCS/ESD) On / Off Valve

Graphic Display on Console : ………………………………………………………………………………………….

INTEGRAL LOOP FUNCTION TEST PLC RECORD PROJECT NO. :

Client : Project title :

LOOP DIAGRAM No. : …………...…………………. rev. :…….. AREA/LOCATION : …………...………………...……………

Analog Input Measuring Scale Range Simulated Local DCS PLC

Alarm / Trip Setting Result

Field Field Indication Panel

Control output Control Control Valve

On / Off Valve On / Off Valve

Field Field D.O / Indication Panel Indication on

Client : Project Title :

Location / Area : …………………………………. Equipment / Panel No. : ………………………………………

Drawing No. : …………………….. rev.: ….. Brand & Manufacture : ……………………………………...

3 Check internal Installation Equipment as per document.

4 Check Support installation.

5 Check Complete All Sim, Bolt, Nuts & Screw.

6 Check Removable Plate,Cable entry protection & Position.

8 No Conflict with Other Installations.

9 Check Tag Number & Name Plate.

10 Check Cable Marking.

11 Check Tube Marking & Cable Lug.

SEQUENCE TEST RECORD Project No.:

Client : Project Title :

Equipment Tag No. of Sequence :

TRANSMITTER INSTALLATION CERTIFICATION RECORD Project No.:

Instr. Type : ……………………………………… Service Line : ………………………………………….

Mfr. : ……………………………………… Output : ………………………………………….