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Page 1 of 1 VETTING APPLICATION FORM This form shall be completed as applicable and send

VETTING APPLICATION FORM

This form shall be completed as applicable and send to e-mail: smr@pertamina.com 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: smr@pertamina.com 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
To: SMR Manager
From
:
Pertamina Shipping
Jl. Yos Sudarso 32-34
Jakarta Utara - 14320
Mail Ref. No.
:
Date
:
Inspection Date
(estimate)
IMO No.
Inspection Port
Owner/Operator
Contact Person
(PIC for Inspection)
Company Phone
Mobile Phone
E-mail
E-mail
Ship Particular & Operational:
Oil
Gas
Chem.
Tanker
SPOB
OB
TB (Other:
)
Charter Type
LTTC
TC
COA
Non-Charter (
)
GT & DWT
Flag
Year of Built
Classification
Non Class
Length Over All
mtr.
Type of Cargo
Breadth
mtr.
Hull type
Single
Double - Hull
Mark as applicable system and or ships operational on board?
Pump room
STS operational
Mother
Shuttle-Tanker
Inert gas system installation
Single point mooring operation
Crude oil washing system
Ice class
(Mention for other)
Expiry Date
Expiry Date
Certificate
Certificate
(dd/mmm/yy)
(dd/mmm/yy)
Class Certificate (H&M)
Safety Management Cert.
Load line Certificate
Document of Compliance
Safety Equipment Cert.
Gas Fitness Cert. (if applicable)
Safety Radio Certificate
Civil Liability Conv. (1992)(>2000DWT)
Safety Construction Cert.
Marine Pollution Insurance (>500GT)
IOPP Certificate
Applicant (Pemohon):
Sign
Company Stamp
Name
Position
Completed by Pertamina - SMR (Ass. Man. Vetting / Vetting Coordinator / Inspector)
Sign
Application form correctly completed?
Name
/
Inspection fees paid accordingly and pay-slip
attached?
Date
/