Pertamina Vetting Application Form

 

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VETTING APPLICATION FORM This form shall be completed as applicable and send to e-mail:  e-mail:   [email protected] or directly addressed to SMR. Incomplete data may result rejection or delay in the inspection schedule. Request to be submitted not later than 14 days before the inspection day. Inspection is preferable to be conducted during discharging. Formulir ini harus diisi dengan benar dan dikirim ke e-mail: [email protected] atau langsung ditujukan kepada SMR. Kurang lengkapnya data dapat mengakibatkan penolakan atau keterlambatan dalam jadwal pemeriksaan. Permintaan untuk disampaikan selambat-lambatnya 14 hari sebelum inspeksi. Inspeksi diutamakan saat kapal melakukan proses bongkar-muatan. 

To: SMR Manager

From

:

Pertamina Shipping Jl. Yos Sudarso 32-34 Jakarta Utara - 14320

Mail Ref. No.

:

Date

:

Ship’s Name 

Inspection Inspecti on Date

IMO No.

Inspection Inspecti on Port

Owner/Operator

Contact Person

Company Phone

Mobile Phone

E-mail

E-mail

(estimate)  

(PIC for Inspection)  

Ship Particular & Operational:  

Ship’s Type

 – Tanker ☐Oil ☐Gas ☐Chem. Chem. –  Tanker ☐SPOB ☐OB ☐TB

Charter Type

☐LTTC ☐TC ☐COA ☐Non-Charter

………………….)) (Other:...…………………. (Other:...

(Other:………………………………………)) (Other:………………………………………

GT & DWT

Flag

Year of Built

Classification

☐ Non

Length Over All

mtr.

Type of Cargo

Breadth

mtr.

Hull type

☐ Single ☐ Double

Class

- Hull

Mark as applicable system and or ships operational on board? ☐ 

Pump room

☐ 

STS operational  ☐ Mother

☐ 

Inert gas system installation

☐ 

Single point mooring operation

☐ 

Crude oil washing system

☐ 

Ice class

Certificate

Expiry Date (dd/mmm/yy)  

☐ Shuttle-Tanker

☐ (Mention for other) 

Expiry Date

Certificate

(dd/mmm/yy)  

Class Certificate (H&M)

Safety Management Cert.

Load line Certificate

Document of Compliance

Safety Equipment Cert.

Gas Fitness Cert.

Safety Radio Certificate

Civil Liability Conv. (1992)(>2000DWT) 

Safety Construction Cert.

Marine Pollution Insurance

(if applicable) 

(>500GT)  

IOPP Certificate

Applicant (Pemohon) :

Sign

Company Stamp

Name Position

Completed by Pertamina - SMR (Ass. Man. Vetting / Vetting Coordinator / Inspector) Application form correctly completed? Name  /   Inspection fees paid accordingly and pay-slip attached?

 /  

Date

Sign