This document is a permit application survey form for a medical facility permit from the Health Agency (Dinas Kesehatan). It requests information on the applicant such as contact details, description of the permit needed to operate a medical facility for employee treatment or emergencies, references to relevant laws and regulations, required supporting documents, application procedures and timelines, permit validity, and notes on costs.

1. PERMIT APPLICATION
Survey Form
INSTITUTION : DINAS KESEHATAN
PERMIT : IJIN FASILITAS MEDICAL
No
Description REVIEW
1 Name Of Section/Directorate
Dr. Juliana CH Ratuanak (Kepala Dinas)
Dr. Lucia F.R.A. Filnditi (Kepala Bidang YANKESMAS)
Dr. B. Clara Sumanik (Kepala Bidang P2MPL)
2 Contact person
Dr. Juliana CH Ratuanak
Dr. Lucia F.R.A. Filnditi ( 081399069800 )
Dr. B. Clara Sumanik ( 085239191933 )
DANIEL ARYESAM (082238116612)
3 Permit/License Description
IJIN PENDIRIAN/ MENGADAKAN FASILITAS MEDICAL
4 Purpose
UNTUK MELAYANI PENGOBATAN ATAU TINDAKAN DARURAT BAGI
KARYAWAN
5
References:
Law/Decree/Regulation
PERATURAN MENTERI KESEHATAN REPUBLIK INDONESIA
NOMOR 028 /MENKES/PER 2011 TENTANG KLINIK
6
Other Authority/Institution
Involved (if any)
KEMENTRIAN KESEHATAN

2. Permit Classification:
 Technical
 Non- Technical
7 Documents Required:
1. SURAT PERMOHONAN KE BUPATI
2. Cq. KEPALA DINAS KESEHATAN
3 AKTE PENDIRIAN PERUSAHAAN
4. SURAT KETERANGAN DOMISILI PERUSAHAAN
5. SUSUNAN PENGURUS DAN COPY KTP
6.TANDA DAFTAR PERUSAHAAN (TDP)
7.NPWP PERUSAHAAN
8.MELAMPIRKAN BIODATA DOKTER/PERAWAT
9. MELAMPIRKAN DAFTAR PERALATAN/JUMLAH ALAT MEDIS YANG
DIGUNAKAN
10. SIUP
Other Documents:
 Study report
 Survey report
 Inspection report
 Design Report
 Other (specify)
8
Detail Procedure:
(Narrative and Flow Chart)
1. SURAT PERMOHONAN DIAJUKAN KEPADA KEPALA DINAS
KESEHATAN
2. SURAT PERMOHONAN DIEVALUASI DAN DIKAJI OLEH TIM TEKNIS
3. SUVEY LOKASI KLINIK DAN PENGECEKAN ALAT MEDIS YANG
DIGUNAKAN
4. DIKELUARKAN REKOMENDASI DARI KEPALA BADAN/ DINAS

3. 9 Detail Duration to apply:
2-6 HARI KERJA KEPALA DINAS MENGELUARKAN REKOMENDASI
TENTANG PERIJINAN TERKAIT KEPADA BUPATI
10 Permits / License Validity:
11
Associated cost:
(Operational Cost)
BEBAS BIAYA (GRATIS)
12 Note:
CATATAN DARI KESEHATAN :
UNTUK TAHUN 2013 PROSES PERIJINAN MEDIS MASIH GRATIS, TETAPI
NANTINYA DITAHUN 2014 AKAN DIADAKAN KANTOR PELAYANAN TERPADU
SATU ATAP YANG AKAN MENGATUR SEMUA BIAYA/TARIF.

5. An Example for Application Procedure and Permit Issuing (Please modify as needed)
Activity
Party
Company Counter
1. Submitting
Application
2. Application
Evaluation
3. Approval
Procedures
1. Company submit the application includes:
a. Request letter
b. Administration requirements:
i. A
ii. B
iii. C
iv. D
v. E
vi. F
vii. G
Apply Verification
Pass? Disposition Disposition
Pass? Pass? Pass?
????
Get Permit
Yes
Yes YesYes
No
No No No
Duration
Duration Duration
Duration

6. viii. H
ix. I
x. J
xi.
c. Technical requirements:
i. K
ii. L
iii. M
iv. N
v. O
vi. P
vii. Q
viii.
d. Other requirement as if needed
2. The application then will be verified by counter officer
3. Passed to ___________________________________
4. Passed to ___________________________________
5. R
6. S
7. T
8. U
9. V
10. W
Note.
a. All activities take about _______ working days
b. If some requirements fail in evaluation, company request to apply again (from step 1).

7. List of Permit:
No PERMIT/LICENSE DESCRIPTION PURPOSE
1 Prohibited Areas and Confined Area Prohibited to enter area of FPSO
2 Permits for entering Oil and gas Area Permit for Vessel entering area of Oil and Gas
3 Pressure Vessel Certification Equipment Safety Worthiness Certificate
4 Pedestal Crane Certification Equipment Safety Worthiness Certificate
5 Rotating Equipment Equipment Safety Worthiness Certificate
6 Electrical Equipment Certification Equipment Safety Worthiness Certificate
7 Flowline (including Flexible pipeline) Equipment Safety Worthiness Certificate
8 LNG Tank Equipment Safety Worthiness Certificate
9 LNG Installation/Plant Installation Operational Safety Worthiness
10 Pressure Safety Valves Final Popping Test Permit to ensure Pressurize Equipment are Protected per Design
11 Welders Performance License for welder performance
12 Welding Procedures Qualification Approval for Welding Procedures
13 Appointing Head of Safety of Mine
(KepalaInspeksi)
Acting as Directorate Technique MIGAS for case of emergency
and all operational technical safety aspects of Plant.
14 Appointing Officer for seal & unsealed Pressure
Safety Valve representing Directorate Technique
of MIGAS
Acting as Directorate Technique MIGAS to seal and unsealed of
All Pressure Safety Valves in case of urgency of the Plant.
15 Centralized Storage use of Hazardous Waste
(B3)
Permits for meeting regulations requirements
16 Desalination Discharge Permit Permits for meeting regulations requirements
17 Hydrotest Water Discharge Permit Permits for meeting regulations requirements
18 Water Discharge Permit During Operation Permits for meeting regulations requirements
19 Permanent Hazardous Storage for Operation Permits for meeting regulations requirements
- Dumping Permit
- Landfill Permit
20 Emission from Non Point (Stationary) Source
Permit
Permits for meeting regulations requirements
21 Noise Level Permit Permits for meeting regulations requirements
22 Odor Level Permit Permits for meeting regulations requirements
23 Vibration Level Permit Permits for meeting regulations requirements
24 Incinerators Permits (Operation Permit) Permits for meeting regulations requirements
25 Forestry Release Permit Permits for meeting regulations requirements
26 Helideck Construction Permit Permit for Construction of Helideck
27 Helipad Construction Permit Permit for Construction of Helipad
28 Operational/landing Permit for Helicopter Permit for Operational of Helicopter
29 Helideck Operation Permit Permit for operation of Helideck
30 FPSO Indonesia Flag Using Indonesia Flag
31 FPSO Construction Approval for Construction of FPSO
32 Buoys for guidance Cargo Ships to FPSO Permit for placing Buoys at appointed points
33 Stipulation on Special Terminal location Location permit respectively for onshore jetty (if any) and the
FLNG as Special Terminal

8. No PERMIT/LICENSE DESCRIPTION PURPOSE
34 Construction Permit for Special Terminal Construction permit respectively for onshore jetty (if any) and the
FLNG as Special Terminal
35 Operation Permit for Special Terminal Operation permit respectively for onshore jetty (if any) and the
FLNG as Special Terminal
36 Working Permit for Under Water work All underwater work shall have permit from Government
37 Dispensation for using Foreign Flag Vessel for
Drilling Activities (IzinPenggunaanKapalAsing)
Dispensation for using Category C and B Vessel
38 Dispensation for using Foreign Flag Vessel for
Installation/Commissioning Activities
(IzinPenggunaanKapalAsing)
Dispensation for using Category C and B Vessel
39 Permit for Marine Telecommunication Marine Communication
40 Operation Permit Permits for Operation of Crew board, vessel, etc
41 Ground Aviation Radio Station Permits for Ground Radio for Flight
42 Dredging works permit Special Terminal Construction
43 Operation Worthiness Permit for Vessel (Surat
IzinLayakOperasi)
Permit for Vessel for Operation in Oil and gas Area
44 Special Vessel Operation Permit/SIOPSUS Permit for FLNG as a vessel to operate within Indonesian water,
as facility supporting the oil and gas operation
45 LNG Tank Volume Calibration Certificates Permits for meeting regulations requirements in
fiscal/Measurement Unit System
46 Custody Transfer Measurement System Usage
Permit - Calibration
Permits for meeting regulations requirements in
fiscal/Measurement Unit System
47 Custody Transfer Measurement System Usage
Permit-Calibration for International Trade
Permits for meeting regulations requirements in
fiscal/Measurement Unit System
48 Producer Imported License (API-P) For importation of materials/Goods
49 Master List Capital Goods Permit for Import of Goods and Materials (Exception of Import
Duty)
50 Import Goods Plan (RIB) Permit for Import of Goods and Materials (Exception of Import
Duty)
51 Approval of Foreign Commercial Loan (PKLN) In respect of foreign loan if the Project is project financed
52 Working Permit for Foreign Personnel- INPEX
Employee (RPTKA & IMTA)
Permit as Basis for Department of Justice to issue KITAS for
Foreign Worker
53 Working Permit for Foreign Personnel for
Contractor's (RPTKA & IMTA)
Permit as Basis for Department of Law and Human Rights to
issue KITAS for Foreign Worker
54 Certification of Lifting Equipment in
Onshore.(Non Oil and Gas Plant)
Permit for using lifting Equipment.
55 Radio Communication Permit (Izin Pita
SpektrumFrekuensi Radio)
Permits for Usage of Marine Radio
57 Principle Permit of Special Telecommunication
Arrangement Permit
Permits for Special Telecommunication
58 Radio and Communication Frequency Permit
For Using During Construction/Commissioning
Permit for Walkie Talkie Permit
59 Permit to use, Store and Transport of
Radioactive materials
To comply with Government Regulation
Survey & Mapping Mapping of the Project Location into Indonesia Chart
License Officer (LO) Permit to use L.O personnel during construction, installation work
62 Survey Vessel Permit Permit for using Survey Vessel and survey activities
63 Clinic Facility License Permit for Clinic Usage
64 Pharmaceutical Storage License Permit for Pharmaceutical/Medicines

9. No PERMIT/LICENSE DESCRIPTION PURPOSE
65 Occupational health and safety (company
doctors, paramedic officials, and expatriate
physician)
Permit for paramedics activities
66 Security Clearance Permit for Entering Indonesia Water
67 Explosive Materials Production, Procurement,
Storage, and Distribution Permit
Explosive material permit
68 Building Permit for Base Camp (IMB) Permit for Building both Temporary and Permanent
69 Land Acquisition (IzinLokasi) Permit for Building both Temporary and Permanent Facilities
70 Land Ownership (HakGunaBangunan) Land Right Used
71 Permit to Use Power Generator (IzinOperasi) For Utilization of Power if INPEX Will provide Own Power
Generator
72 Letter of Recommendation from Regional
Government (BUPATI) for Special Terminal
Recommendation Letter for Special Terminal
73 Permit to Use Heavy Equipment from Public
Works Office-Regional Government
(KABUPATEN)
Permit for using Heavy Equipment
74 Compulsory Report of Company's existence
employee in the region
Reporting on current number of National and foreign employee
working in the region
75 Permit for doing business in the region To register INPEX office in the region
76 Compulsory Report of Company's existence
employee in the region
Reporting on current number of National and Working Permit of
foreign employee that are working in the region
77 Building Permit (IMB) Explosive & Detonator Storage
78 Building Permit (IMB) Construction of Fuel Storage
79 Building Permit (IMB) Construction of Hangar & other buildings (Permanent &
Temporary)
80 Permits of Ground Water Extraction Usage of Ground Water
81 Permits of Surface Water Usage Surface Water
82 Building Permit (IMB) Clinic Facility, Dining & Kitchen Facility
83 Construction Permit Infrastructure Construction (Public Road & Drainage)
84 Site Representative Office For Rep office before FEED Phase (Temporary )
85 Letter of Domicile of INPEX/Contractor Permit for domicile
86 Landing Permit for Heavy Duty Construction
Equipment
Permit for usage of Heavy Equipment
87 Fuel Allocation for Project Purpose/Annual
Allocation
Letter of approval for supplying fuel for INPEX On Shore
operation