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LAMPIRAN III

Standard Formulir Aktivitas Kapal


di Pelabuhan
1. Compartment Log Sheet
2. Delivery Certificate
3. Disch Agreement
4. Dry After Disch Certificate
5. Dry Before Loading Certificate
6. Inspection Record
7. Letter of Discrepancy
8. Letter of Protest Pumping Rate
9. Loading Agreement
10. Log Abstract
11. Master Cable
12. Master Requisition
13. Notice of Readiness
14. Notice of Sealing
15. Off Hire Certificate
16. On Hire Certificate
17. Oil Spill
18. Pumping Log
19. Redelivery Certificate
20. ROB Bunker
21. Sailing Order
22. Ship Condition
23. Statement of fact
24. Statement of Reduce rate
25. Stop Temporary
26. Tanker Time Sheet
27. Ullage Report

PT PERTAMINA (PERSERO)
SHIPPING MARKETING & TRADING DIRECTORATE

SHIPPING OPERATION DIVISION, HEAD OFFICE 19TH Floor, Jln. Merdeka Timur 1A Jakarta 10110
Phone : (62-21) 3816367, 3816314, 3816339, 3816353, 3816217. Fax : 3455430, 3816348, 3507121
E-mail: opstanker@pertaminashipping.com

COMPARTMENT LOGSHEET
AFTER/BEFORE/LOADING/DISCHARGING
VESSELS NAME
PORT / DATE
VOYAGE
CARGO
TANKS
NO
(1)
PORT
1
2
3
4
5
6
7
8
CENTER
1
2
3
4
5
6
7
8
STBD
1
2
3
4
5
6
7
8
TOTAL

:
:
:

DRAFT (Mtr)
BEFORE LOAD / DISCH
AFTER LOAD / DISCH
TANK OBSERVATION

GRADE

CORR
ULL

GROSS
VOL (KL)

(2)

(3)

(4)

LOADING MASTER

SAMPLES OBS
FREE WATER
VOL
DIP
(KL)
(5)
(6)

NET
VOL
(KL)
(7)

DENS

TEMP
(oC )

DENSITY
@ 15C
(TABLE 53)

VOL COR
FACTOR
(TABLE 54)

NET KL
@ 15C

(8)

(9)

(10)

(11)

(12)

PT. PERTAMINA (PERSERO)


Shipping Representative/Agent

VOLUME
CONV
FACTOR
(TABLE 52)
(13)

:
:

BARRELS
@60F
(14)

WEIGHT
CONV
FACTOR
(TABLE 57)
(15)

CHIEF OFFICER

LONG
TONS

METRIC
TONS

(16)

(17)

PT PERTAMINA (PERSERO)
SHIPPING MARKETING & TRADING DIRECTORATE
TH

SHIPPING OPERATION DIVISION, HEAD OFFICE 19 Floor, Jln. Merdeka Timur 1A Jakarta 10110
Phone : (62-21) 3816367, 3816314, 3816339, 3816353, 3816217. Fax : 3455430, 3816348, 3507121
E-mail: opstanker@pertaminashipping.com

DELIVERY CERTIFICATE

This is to certify that MT / SS / TB :


Call Sign
Flag :
Gross Tons :
was duly delivered
by the Master (for and on behalf of Owner), to and accepted :by
PT PERTAMINA (PERSERO)
(for and on behalf of Charterer), at
hours local time, on

It was also agreed at that time that the vessel had onboard bunker and fresh
water as follows :
water as

Marine Fuel Oil


Marine Diesel Oil
Autogas (HSD)
Fresh Water

:
:
:
:

Metric Ton.
Metric Ton.
Metric Ton.
Ton.
Port
Date

:
:

:
Port
PT PERTAMINA (PERSERO)
Representative

(For and on behalf of Charterer)

Master MT / SS / TB

(For and on behalf of Owner)

PT. PERTAMINA (PERSERO)


DIREKTORAT PEMASARAN DAN NIAGA - PERKAPALAN

LOADING/DISCHARGING AGREEMENT
Name of Ship
Voy No.
Date
Berth/Jetty

:..........................
:..........................
:..........................
:..........................

Disch. Port

:......................

Loading Port

:......................

Draft
F : . . . . . . . . . Mtr
M : . . . . . . . . . Mtr
A : . . . . . . . . . Mtr

RECEIVING AVAILABILITY AND CAPACITY


Shore

Ship's
Grade

Line(LA) use &

Load/Disch. Rate

KL/hrs

Pressure

kg/cm2

C O P use

Line =

inchi

Line=

inchi

Quantity Load/Disch
in KL Obs

KL/hrs 1.
kg/cm2 2.

COP

3.

Total Quantity Load/ Discharge =


Load/Disch. Rate / Pressure at Manifold as Agreement : . . . . . . . . . . . . .KL/hrs - . . . . . . . . . . .kg/cm 2
Estimated Completed Load/Disch. time
(including stripping)

.........................
Loading Master
Remark :

: . . . . . . . . . . . . . . . . . . .hrs

......................
Master

In the event the discharging rate/pressure at manifold of the vessel is below the agreement mention above
then the vessel will be claim for slow pumping, if the slow pumping is caused by the vessel fault.
...............................................................................................
...............................................................................................
...............................................................................................
Note
:
Line
: Pipa (muat / bongkar)
SFBD : Ship's Figure Beofore Discharge
F : Forward (depan)
LA
: Loading Arm (pipa muat)
Voy No.: Voyage No. (No. Pelayaran)
M : Mid (tengah)
COP
: Cargo Oil Pump (pompa utama) KL Obs : Kilo Liter Observasi (pengamatan)
A : After (belakang)
Line
: Diameter pipa dalam inchi
Shore : Darat
Hrs : Jam
Grade
: Jenis Muatan
Berth/Jetty : Nama tempat sandar (dermaga/SBM)
- Kegiatan bongkar harus direcord dalam pumping log dan ditandatangani pihak kapal dan pihak darat.
- Penurunan tekanan / rate atas permintaan darat/kapal harus dibuat secara tertulis dan ditandatangani pihak kapal &
darat

PT PERTAMINA (PERSERO)
SHIPPING MARKETING & TRADING DIRECTORATE
TH

SHIPPING OPERATION DIVISION, HEAD OFFICE 19 Floor, Jln. Merdeka Timur 1A Jakarta 10110
Phone : (62-21) 3816367, 3816314, 3816339, 3816353, 3816217. Fax : 3455430, 3816348, 3507121
E-mail: opstanker@pertaminashipping.com

DRY CERTIFICATE
(After Discharging)

PORT:
DATE:

20

To:
I, the Loading Master, have inspected all ships tanks
at
hours local time, on
and found dry & empty.

20

All cargo on board has been delivered in good order and condition
Remark:
Quantity of ROB
or OBQ

Yours truly,

Loading Master

To Loading Master,
We confirmed acceptance of your written dry certificate at
hours local time, on

Yours truly,

Master

PT PERTAMINA (PERSERO)
SHIPPING MARKETING & TRADING DIRECTORATE
TH

SHIPPING OPERATION DIVISION, HEAD OFFICE 19 Floor, Jln. Merdeka Timur 1A Jakarta 10110
Phone : (62-21) 3816367, 3816314, 3816339, 3816353, 3816217. Fax : 3455430, 3816348, 3507121
E-mail: opstanker@pertaminashipping.com

DRY CERTIFICATE
(Before Loading)

PORT:
DATE:

20

To:
I, the Master of
at
and found dry & clear.

, have inspected all ships tanks


hours local time, on
20

And ready to commence loading of the cargo


Remark:
Quantity of ROB
or OBQ

:
:

Yours truly,

Master
To Master of MT,
We confirmed acceptance of your written dry certificate at
hours local time On
Yours truly,

Loading Master

PT PERTAMINA (PERSERO)
SHIPPING MARKETING & TRADING DIRECTORATE

SHIPPING OPERATION DIVISION, HEAD OFFICE 19TH Floor, Jln. Merdeka Timur 1A Jakarta 10110
Phone : (62-21) 3816367, 3816314, 3816339, 3816353, 3816217. Fax : 3455430, 3816348, 3507121
E-mail: opstanker@pertaminashipping.com

INSPECTION RECORD

BOTTOM
SHIPS COMP.

(1)
PORT

CENTER

STBD

WALL

VALVE

HEATING COILS

HEATING COILS

Empty

Free
Water

Clean

D/S/WP

Clean

D/S/WP

O/C

Sealed

Sealed
Number

D/S

Leak

Empty

Content

(2)

(3)

(4)

(5)

(6)

(7)

(8)

(9)

(10)

(11)

(12)

(13)

(14)

1
2
3
4
5
6
7
8
1
2
3
4
5
6
7
8
1
2
3
4
5
6
7
8

Cofferdam
Slop Tank
Fore Peak Tank
After Peak Tank

Notes: Oil Inspector for Cleanliness :


Loading Master
: for Cargo
Discharging Master

P&T Agent

Oil Inspector/ Loading Master


Discharging Master

Mualim I / Chief Officer

PT PERTAMINA (PERSERO)
SHIPPING MARKETING & TRADING DIRECTORATE
TH

SHIPPING OPERATION DIVISION, HEAD OFFICE 19 Floor, Jln. Merdeka Timur 1A Jakarta 10110
Phone : (62-21) 3816367, 3816314, 3816339, 3816353, 3816217. Fax : 3455430, 3816348, 3507121
E-mail: opstanker@pertaminashipping.com

SURAT PERBEDAAN ANGKA MUATAN


LETTER OF DISCREPANCY
Tanggal
Date

Voyage

Pelabuhan
Port

Kepada
To
Dari Nakhoda
From Master

:
:

Setelah pengecekan kembali dengan teliti figures


muatan yang dimuat serta disesuaikan dengan draft
dan deadweight dari kapal kami, maka terdapat
perbedaan lebih dari setengah () persen antara B/L
figures dengan ships figures dengan perincian
sebagai berikut :
Jenis
Grade

Angka Kapal
Ship Figures

After having been rechecked the figures of the


cargo loaded carefully and compared it with the
draft and deadweight of our vessel, a difference
of more than half () percent between B/L and
the ships figures has been found as follows :

No. dan angka B/L


No. and B/L figures

Selisih
Difference

Bbls

Bbls

Bbls

Bbls

Bbls

Bbls

Berdasarkan figures tersebut diatas dengan ini kami


menyatakan bahwa B/L telah kami tandatangani
dibawah protes dengan ketentuan bahwa kapal
tidak dapat dipertanggung jawabkan atas figures
pembongkaran pada pelabuhan bongkar.

Base on above mentioned figures, we here by


declare that the B/L has been signed under
protest, notably that the ship could not be hold
responsible for the outturn figures at the
discharging port.

Catatan :

Remarks :

Tanker Ullage Report pertama dan kedua diukur


dan dihitung bersama-sama Loading Master serta
Agen dan telah diserahkan ke perwakilan/Agen
PT. PERTAMINA (PERSERO).

The first and the second Tanker Ullage Report


already measure and calculated together with
Loading Master and Agent and send to
PT. PERTAMINA (PERSERO) Representative.

Hormat kami
Yours faithfully
Nakhoda
Master

Diketahui
Known by
PT PERTAMINA (PERSERO)
Representative

PT PERTAMINA (PERSERO)
SHIPPING MARKETING & TRADING DIRECTORATE
TH

SHIPPING OPERATION DIVISION, HEAD OFFICE 19 Floor, Jln. Merdeka Timur 1A Jakarta 10110
Phone : (62-21) 3816367, 3816314, 3816339, 3816353, 3816217. Fax : 3455430, 3816348, 3507121
E-mail: opstanker@pertaminashipping.com

LETTER OF PROTEST
Slow Pumping

To

DATE

PORT

BERTH

As recorded, that my vessel is capable to loading / discharging cargo at


TONS/BBLS/M3 per hour with
line

inches connection. However, shore can only supply /receive of


TONS/BBLS/M3 per hour

line. Equivalent to

hours actual loading /discharging time.

In view of the foregoing, I Master of MT

protest the delay of

loading / discharging and on behalf of my Owners and Consignee / Charterer reserves


their right to claim you for all time losses and expenses incured, if any, and that such
claims to forthcome at an appropriate time and place my principal deemed it.

Port of

Date

Loading Master

Master / Duty Officer

PT PERTAMINA (PERSERO)
SHIPPING MARKETING & TRADING DIRECTORATE
TH

SHIPPING OPERATION DIVISION, HEAD OFFICE 19 Floor, Jln. Merdeka Timur 1A Jakarta 10110
Phone : (62-21) 3816367, 3816314, 3816339, 3816353, 3816217. Fax : 3455430, 3816348, 3507121
E-mail: opstanker@pertaminashipping.com

LOG ABSTRACT
(The voyage should cover the period End of Sea Voyage as per Log at first Loading Port until return same position Next Loading Port, after discharging all cargo)
VESSEL NAME :

Port

VOYAGE NO :

PORT TIME :
(Loading / Discharging)
End of Sea Voyage
Begin Of Sea Voyage
Date
Time
Date
Time

Cargo Load / Disch. (Long Ton)


B/L
SFAL/SFBD
Grade

Port Time
(Hours)

Remark :

SEA PASSAGE :
From
(BOSV)
Port:
Date:

Time:

Port

(Laden / Ballast)
To
(EOSV)
Port:
Date:

Distance
(Miles)

Steaming
Time (Hours)

Av. Speed
(Knots)

MFO

Fuel & FW Consumption (MT)


MDO
HSD

Date

Time

PORT TIME :
(Loading / Discharging)
End of Sea Voyage
Begin Of Sea Voyage
Date
Time
Date
Time

Cargo Load / Disch. (Long Ton)


B/L
SFAL/SFBD
Grade

Port Time
(Hours)

St. by. Eng. (EOSV)


FWE
St. by. Eng.
FWE
Comm. Load/Disc.
Complt. Load/Disc.
St. by. Eng.
FWE
St. by. Eng.
Full Away (BOSV)

SEA PASSAGE :
From
(BOSV)
Time:

(Laden / Ballast)
To
(EOSV)
Port:
Date:

Distance
(Miles)

Steaming
Time (Hours)

Av. Speed
(Knots)

MFO

Fuel & FW Consumption (MT)


MDO
HSD

FW

Time:

Hours

Description
Heat
Tk. Clean
IGS

Date

Time

Description

Hours

Steaming in/out
Idle
Load/ Disch
Ballast/ Deballast
Cargo Heating
IGS
Total
ROB ATA
ROB ATD
REPLENISHMENT
Description
Heat
Tk. Clean
IGS

Hours

Deviation to storing and / or repair port :


Miles.
Date / Hour
Date / Hour
Hour
DO :

HSD :

FW :

Fuel & FW Counsumption (MT)


MDO
HSD

FW

MFO

Fuel & FW Counsumption (MT)


MDO
HSD

FW

Hours

State exast periods of delay caused by accident engine trouble crew heavy weather and the like :

Distance to go at time of deviation to next loading / discharging port :


Place / Point of Deviation
Returned to point of deviation or corresponding position
Actual periode of deviation : Days
Bunker and F.W. consumed during the deviation periode FO :

MFO

ROB ATA
ROB ATD
REPLENISHMENT

FW

Activity

Description
Steaming in/out
Idle
Load/ Disch
Ballast/ Deballast
Cargo Heating
IGS
Total

Time:

Remark :

Port:
Date:

Activity
St. by. Eng. (EOSV)
FWE
St. by. Eng.
FWE
Comm. Load/Disc.
Complt. Load/Disc.
St. by. Eng.
FWE
St. by. Eng.
Full Away (BOSV)

Master

Chief Engineer

PT PERTAMINA (PERSERO)
SHIPPING MARKETING & TRADING DIRECTORATE
TH

SHIPPING OPERATION DIVISION, HEAD OFFICE 19 Floor, Jln. Merdeka Timur 1A Jakarta 10110
Phone : (62-21) 3816367, 3816314, 3816339, 3816353, 3816217. Fax : 3455430, 3816348, 3507121
E-mail: opstanker@pertaminashipping.com

RE : DEPARTURE MASTER CABLE


ROC. 1863 / OT II DATED 18 / 08 / 1999 AS TO GET A COMPLETE DEPARTURE
MESSAGE. YOU ARE REQUESTED TO ADVISE ALL DETAILS BELOW AT THE FIRST
PRIORITY FOR EACH ACTIVITY:
AA.
BB.
CC.
DD.
EE.
FF.
GG.
DD.
EE.
FF.
GG.
HH.
II.
JJ.
KK.
LL.
MM.
NN.
OO.
PP.
QQ.
RR.
SS.
TT.
UU.
VV.
WW.
XX.
YY.

THANKS FOR YOUR ATTENTION COOPERATION ACK REGARDS.

PT PERTAMINA (PERSERO)
SHIPPING MARKETING & TRADING DIRECTORATE
TH

SHIPPING OPERATION DIVISION, HEAD OFFICE 19 Floor, Jln. Merdeka Timur 1A Jakarta 10110
Phone : (62-21) 3816367, 3816314, 3816339, 3816353, 3816217. Fax : 3455430, 3816348, 3507121
E-mail: opstanker@pertaminashipping.com

MASTERS REQUISITION

Port
Date

:
:

Dear Sir :
Please supply my vessel the as / my :

With,

MARINE FUEL OIL


Maximum viscosity redwood 1 @ 100 o F
Rate per hour for delivery

KL / MT
Seconds

MARINE DIESEL FUEL


Rate per hour for delivery

KL / MT

GAS OIL
Rate per hour for delivery

KL / MT

DRINGKING WATER

Tons

BOILER WATER

Tons

And charge same to my Principals namely :

I require the grades to be supplied in the following order :


And * will / * will not appoint a representative to withness and check either the opening and closing meter
readings/ calculations or if meters no available, the opening and closing tank dips/calculations only
behalf.
The ship / * there will give the final stop pumping signal.

Your very truly


Master MT :

PT PERTAMINA (PERSERO)
SHIPPING MARKETING & TRADING DIRECTORATE
TH

SHIPPING OPERATION DIVISION, HEAD OFFICE 19 Floor, Jln. Merdeka Timur 1A Jakarta 10110
Phone : (62-21) 3816367, 3816314, 3816339, 3816353, 3816217. Fax : 3455430, 3816348, 3507121
E-mail: opstanker@pertaminashipping.com

NOTICE OF READINESS
Voy. No.

PORT
DATE
TIME TENDERED

:
:
:

To:
Dear Sir,
I hereby tender you the MT
at the date time shown above as being ready in all respect to commence the
loading/ discharging of her cargo
consisting of:
Description of cargo

Approximate amount/Bill of Lading quantity

Laytime will commence as specified in the charter party covering this voyage

ACCEPTED
Date :

Very truly yours


Hour:

By :
as Agent

Master

PT PERTAMINA (PERSERO)
SHIPPING MARKETING & TRADING DIRECTORATE
TH

SHIPPING OPERATION DIVISION, HEAD OFFICE 19 Floor, Jln. Merdeka Timur 1A Jakarta 10110
Phone : (62-21) 3816367, 3816314, 3816339, 3816353, 3816217. Fax : 3455430, 3816348, 3507121
E-mail: opstanker@pertaminashipping.com

NOTICE OF SEALING
No :

After completing :
Loaded in tank :

cargo

Of the MV / MT :
On the
:
The following valves and tanklide were sealed by Loading
Number and name valves/tanklide sealed

Total

:
:
:
:
:
:
:
:
:
:
:
:
:

pcs
pcs
pcs
pcs
pcs
pcs
pcs
pcs
pcs
pcs
pcs
pcs

20
Scaling Acknowledge by :

Signature

Chief Engineer

Loading Master

Cc

: Consignee
Chief Officer
Pelsus
Inst. Tank

PT PERTAMINA (PERSERO)
SHIPPING MARKETING & TRADING DIRECTORATE
TH

SHIPPING OPERATION DIVISION, HEAD OFFICE 11 Floor, Jln. Merdeka Timur 1A Jakarta 10110
Phone : (62-21) 3816367, 3816314, 3816339, 3816353, 3816217. Fax : 3455430, 3816348, 3507121
E-mail: opstanker@pertaminashipping.com

OFF HIRE CERTIFICATE


This is to certify that MT / SS / TB :
Call Sign:

DWT :

Flag :
was duly off hire by PT PERTAMINA (PERSERO)

(for and on behalf of Charterer), to and accepted by Master (for and on behalf of
owner), at

hours local time, on

It was also agreed at that time that the vessel had onboard bunker and fresh water
as follows :
Marine Fuel Oil (180cst/380cst)*
Marine Diesel Oil
Autogas (HSD)
Marine Gas Oil (MGO)
Fresh Water

:
:
:
:
:

Metric Ton.
Metric Ton.
Metric Ton.
Metric Ton.
Ton.

*)coret yang tidak perlu

Port
Date

Master MT / SS / TB

(For and on behalf of Owner)

:
:

PT PERTAMINA (PERSERO)
Representative
(For and on behalf of Charterer)

PT PERTAMINA (PERSERO)
SHIPPING MARKETING & TRADING DIRECTORATE
TH

SHIPPING OPERATION DIVISION, HEAD OFFICE 19 Floor, Jln. Merdeka Timur 1A Jakarta 10110
Phone : (62-21) 3816367, 3816314, 3816339, 3816353, 3816217. Fax : 3455430, 3816348, 3507121
E-mail: opstanker@pertaminashipping.com

LAPORAN PEMERIKSAAN PENCEGAHAN TUMPAHAN MINYAK DI PERAIRAN


1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.

Kapal
Terminal
Pemilik Kapal
Dioperasikan oleh
Agen
Nama
Alamat
Nama Nakhoda
Tiba di
Tgl
jam
Di dermaga
Tgl
jam
Berlabuh jangkar dari jam
Tgl
sampai jam
Tgl
Jenis muatan
Apakah Oil Boom dipasang
Apakah kerangan-kerangan pipa pembuangan air ballast kotor / air got ke laut tertutup rapat sebelum
penyegelan
Apakah semua penutup lubang untuk mengukur minyak di tangki muatan (ullage cover screens) ada pada
tempatnya sebelum pemompaan dimulai
Jumlah segel yang digunakan
Jumlah dispersant yang ada di kapal
Jenis
Merk Pabrik
Tanda tangan Perwira dan Pemeriksa Darat yang melaksanakan penyegelan :

Perwira Kapal
15. Apakah saluran pembuangan air dek
kapal sudah disumbat sebelum
pompa dihidupkan

16.
17.

18.

Pemeriksa Darat
Apakah talang penadah tumpahan
minyak berada dibawah manifold
kapal

Apakah talang penadah tumpahan


minyak untuk kapal tersedia di darat.

Slang terakhir telah terpasang


jam
tgl
20
Pembongkaran/pemuatan dimulai jam
tgl
20
Selesai pembongkaran/pemuatan jam
tgl
20
Slang terakhir dilepas
jam
tgl
20
Apakah ujung slang terakhir telah tertutup rapat waktu dimulainya pemompaan ballast diatas kapal
sebelum diturunkan ke darat
jam
tgl
20
Waktu segel dibuka untuk pengisian air ballast apakah segel-segel masih utuh sebelum dibuka
jam
tgl
20
Tanda tangan Perwira Kapal dan Pemeriksa Darat waktu membuka segel :

Perwira Kapal
19. Apakah saluran pembuangan air
dek
kapal
sudah
disumbat
sebelum pompa dihidupkan

Apakah talang penadah tumpahan


minyak berada dibawah manifold kapal

(
)
Pemeriksa Darat
Apakah talang penadah tumpahan
minyak untuk kapal tersedia di darat.

20.

Bilamana ada minyak terlihat diatas air disekitar kapalberikan laporan terperinci dibawah ini :

21.

Data Kapal
- DWT
- GRT
- LOA
- FLAG

:
:
:
:
:

PT PERTAMINA (PERSERO)
SHIPPING MARKETING & TRADING DIRECTORATE
TH

SHIPPING OPERATION DIVISION, HEAD OFFICE 19 Floor, Jln. Merdeka Timur 1A Jakarta 10110
Phone : (62-21) 3816367, 3816314, 3816339, 3816353, 3816217. Fax : 3455430, 3816348, 3507121
E-mail: opstanker@pertaminashipping.com

ON HIRE CERTIFICATE
This is to certify that MT / SS/ TB :
Flag :
Call Sign:
DWT :
was duly on hire by the Master
(for and on behalf of Owner) to and accepted by PT PERTAMINA (PERSERO)
(for and on behalf of Charterer),
at
hours local time, on
It was also agreed at that time that the vessel had onboard bunker and fresh water
as follows :
Marine Fuel Oil (180cst/380cst)*
Marine Diesel Oil
Autogas (HSD)
Marine Gas Oil (MGO)
Fresh Water

:
:
:
:
:

Metric Ton.
Metric Ton.
Metric Ton.
Metric Ton.
Ton.

*)coret yang tidak perlu

Port
Date
PT PERTAMINA (PERSERO)
Representative
(For and on behalf of Charterer)

:
:
Master MT / SS / TB

(For and on behalf of Owner)

PT PERTAMINA (PERSERO)
SHIPPING MARKETING & TRADING DIRECTORATE
TH

SHIPPING OPERATION DIVISION, HEAD OFFICE 19 Floor, Jln. Merdeka Timur 1A Jakarta 10110
Phone : (62-21) 3816367, 3816314, 3816339, 3816353, 3816217. Fax : 3455430, 3816348, 3507121
E-mail: opstanker@pertaminashipping.com

ON HIRE CERTIFICATE
This is to certify that MT / TT/ TB :
Flag :
Call Sign:
DWT :
was duly on hire by the Master
(for and on behalf of Owner) to and accepted by PT PERTAMINA (PERSERO)
(for and on behalf of Charterer),
at
hours local time, on
It was also agreed at that time that the vessel had onboard bunker and fresh water
as follows :
Marine Fuel Oil
Marine Diesel Oil
Autogas (HSD)
Fresh Water

:
:
:
:

Metric Ton.
Metric Ton.
Metric Ton.
Ton.

Port
Date
PT PERTAMINA (PERSERO)
Representative
(For and on behalf of Charterer)

:
:
Master MT / TT / TB

(For and on behalf of Owner)

PT PERTAMINA (PERSERO)
SHIPPING - MARKETING & TRADING DIRECTORATE
SHIPPING OPERATION DIVISION, PT PERTAMINA (PERSERO) HEAD OFFICE 11 TH Floor, Jln. Merdeka Timur 1A Jakarta 10110
Phone : (62-21) 3816367, 3816314, 3816369, 3816353, 3816217. Fax : 3455430, 3816348, 3507121
E-mail: opstanker@pertaminashipping.com

PUMPING / DISCHARGE LOG


MT

PORT OF

DATE

AVERAGE PRESS MAINTAINED SHIP RAIL

:
:

kg/m2
kg/m2

NO OF PUMP

NORMAL SERV. RPM

NO OF HOSE
SHORE LINES NO

:
:

inches
inches

DATE

NO

HOURS

PRESS ALLOW BY SHORE ON HOSE

MAIN PUMP NO.1


PRESS PUMPING
AT RAIL
RATE
RPM
(kg/cm2)
(m3/h)

CARGO GRADE AND


QUANTITY

SG/
DENSITY

MAIN PUMP NO.2


PRESS
PUMPING
AT RAIL
RATE
RPM
(kg/cm2)
(m3/h)

TEMP OBSERVED
(oC)

MAIN PUMP NO.3


PRESS PUMPING
AT RAIL
RATE
RPM
(kg/cm2)
(m3/h)

:
:

SIZE
SIZE

MAIN PUMP NO.4


PRESS PUMPING
AT RAIL
RATE
RPM
(kg/cm2)
(m3/h)

COMMENCED DISCHARGE

COMPLETED DISCHARGE

DATE

DATE

HOUR

MINUTE

HOUR

MINUTE

REMARKS

DISCH.
TIME

2
3

TOTAL
STOP

STOP DISCHARGE

FROM

TO

5
6
7
PRESSURE RECORDED SHIP' RAIL / UPPER PUMP ROOM / LOWER PUMP ROOM :
IF ANY PUMP WAS NOT IN OPERATION ADVISE REASON :
IF DISCHARGEING INTERUPTED ADVISE REASON :
IF NORMAL RPM WERE NOT MAINTAINED ADVISE REASON :
IF ANY DELAY INCURRED DUE TO SHORE ORDER ATTACH WRITTEN INSTRUCTION :
PT PERTAMINA (PERSERO)
Representative

CHIEF OFFICER

MASTER

REASON

PT PERTAMINA (PERSERO)
SHIPPING MARKETING & TRADING DIRECTORATE
TH

SHIPPING OPERATION DIVISION, HEAD OFFICE 11 Floor, Jln. Merdeka Timur 1A Jakarta 10110
Phone : (62-21) 3816367, 3816314, 3816339, 3816353, 3816217. Fax : 3455430, 3816348, 3507121
E-mail: opstanker@pertaminashipping.com

REDELIVERY CERTIFICATE
This is to certify that MT / SS / TB :
Flag :
DWT :

Call Sign :
was duly redelivered by
PT PERTAMINA (PERSERO)
(for and on behalf of Charterer), to and accepted by Master (for and on behalf
Owner), at
hours local time, on
of
It was also agreed at that time that the vessel had onboard bunker and fresh
water as follows :
Marine Fuel Oil (180cst/380cst)*
Marine Diesel Oil
Autogas (HSD)

:
:
:

Metric Ton.
Metric Ton.
Metric Ton.

Marine Gas Oil (MGO)


Fresh Water

:
:

Metric Ton.
Ton.

*) coret yang tidak perlu

Port
Date

:
:

Master MT / SS / TB

PT PERTAMINA (PERSERO)
Representative

(For and on behalf of Owner)

(For and on behalf of Charterer)

PT PERTAMINA (PERSERO)
SHIPPING MARKETING & TRADING DIRECTORATE
TH

SHIPPING OPERATION DIVISION, HEAD OFFICE 11 Floor, Jln. Merdeka Timur 1A Jakarta 10110
Phone : (62-21) 3816367, 3816314, 3816339, 3816353, 3816217. Fax : 3455430, 3816348, 3507121
E-mail: opstanker@pertaminashipping.com

BUNKER REMAIN ON BOARD


ATA / ATD
VESSELS NAME

VOYAGE

DATE

PORT

DRAFT

Mtr

Mtr

Mtr

MFO / IFO TANKS :


NO TANK

ULLAGE /
SOUNDING

VOLUME
(KL / M3 )

TEMP
o
( C)

SG

TANKS
VCF

METRIC
TON

VOLUME
(KL / M3 )

TEMP
o
( C)

SG

TANKS
VCF

METRIC
TON

TOTAL
MDO / HSD / MGO TANKS :
NO TANK

ULLAGE /
SOUNDING

TOTAL
All bunker tanks has been inspected and calculated together between :
PT. PERTAMINA (PERSERO)
Representative

Note :

Average for SG MFO = 0.921 ; MDO = 0.856 ; HSD = 0.838


(ref. kpts no.074/C0000/96B1 dated April 22, 1996)

Chief Engineer :

PT PERTAMINA (PERSERO)
SHIPPING MARKETING & TRADING DIRECTORATE
TH

SHIPPING OPERATION DIVISION, HEAD OFFICE 19 Floor, Jln. Merdeka Timur 1A Jakarta 10110
Phone : (62-21) 3816367, 3816314, 3816339, 3816353, 3816217. Fax : 3455430, 3816348, 3507121
E-mail: opstanker@pertaminashipping.com

SAILING ORDER

To : Master MT/TT/TB

Dear sir,
Please proceed to

on

of Loading/Discharging at
Cargo

Date

No

after completion
, for Loading/Discharging as follows :

Quantities :

Destination

The complete information about next port will sent via telex if necessary.
Please follow the instruction from Tanker Operation.

Yours truly
PT PERTAMINA (PERSER0)
Representative

PT PERTAMINA (PERSERO)
SHIPPING MARKETING & TRADING DIRECTORATE
TH

SHIPPING OPERATION DIVISION, HEAD OFFICE 19 Floor, Jln. Merdeka Timur 1A Jakarta 10110
Phone : (62-21) 3816367, 3816314, 3816339, 3816353, 3816217. Fax : 3455430, 3816348, 3507121
E-mail: opstanker@pertaminashipping.com

SHIP CONDITION
MT
LAST PORT CONDITION FROM :

ARRIVAL :

REPLENISHMENT

DEPARTURE TO:

DATE
TIME

DATE
TIME

DATE
TIME

:
:

DATE
TIME

:
:

MFO
MDO
HSD

:
:
:

MFO
MDO
HSD

:
:
:

:
:

:
:

BUNKER

BUNKER

MFO :
MDO :
HSD :

MT
MT
MT

MFO :
MDO :
HSD :

FRESH WATER
BW
FW

FRESH WATER

:
:

Tons
Tons

BW :
FW :

BW
FW

:
:

Mtr FORE
Mtr AFTER
N /Miles

MT
MT
MT

FRESH WATER
Tons
Tons

BW
FW

:
:

Tons
Tons

DRAFT

:
:
:

PORT
PELABUHAN
DATE
TANGGAL

BUNKER
MT
MT
MT

FRESH WATER
Tons
Tons

DRAFT
Fore
After
Total
Distance

BUNKER
MT
MT
MT

DRAFT
Mtr
Mtr

Fore
After

:
:

Master / Chief Officer

:
( .. )

Mtr
Mtr

PT PERTAMINA (PERSERO)
SHIPPING MARKETING & TRADING DIRECTORATE
TH

SHIPPING OPERATION DIVISION, HEAD OFFICE 11 Floor, Jln. Merdeka Timur 1A Jakarta 10110
Phone : (62-21) 3816367, 3816314, 3816339, 3816353, 3816217. Fax : 3455430, 3816348, 3507121
E-mail: opstanker@pertaminashipping.com

Statement Of Fact
(Ship Unreadiness and Readiness)
To whom it may concern
I the Master of MT/SS/TB.
Flag :
Declare that vessel is not ready on the date :
(hours local time)
In the position
ROB for

Remarks

MFO (180cst/380cst)
MDO
HSD
MGO
FW

Remarks

DWT :
hour :
while

:
:
:
:
:

MT.
MT.
MT.
MT.
Ton.

Vessel is ready for :


Date :
ROB for

Call sign :

Hour

(hours local time)

MFO (180cst/380cst)

MT.

MDO

MT.

HSD

MT.

MGO

MT.

FW

Ton.

Port :
Date :
Acknowledge
PT. PERTAMINA (PERSERO)
Representative

Master MT /SS/ TB :

PT PERTAMINA (PERSERO)
SHIPPING MARKETING & TRADING DIRECTORATE
TH

SHIPPING OPERATION DIVISION, HEAD OFFICE 19 Floor, Jln. Merdeka Timur 1A Jakarta 10110
Phone : (62-21) 3816367, 3816314, 3816339, 3816353, 3816217. Fax : 3455430, 3816348, 3507121
E-mail: opstanker@pertaminashipping.com

Statement of Reduce Rate


of Loading / Discharging
To whom it may concern
I, Master MT

stated that, today,

date
at

at port
hours local time, as requested by The Loading Master,
,to temporary reduce discharging/ loading rate of cargo

from

M3 / sec

M3 / sec

to

from

hours local time,

until

hours local time.

due to :

Kindly sign and return the copy of this letter of acknowledgement.

Loading Master

Port of

Date

Master / Duty Officer

PT PERTAMINA (PERSERO)
SHIPPING MARKETING & TRADING DIRECTORATE
TH

SHIPPING OPERATION DIVISION, HEAD OFFICE 19 Floor, Jln. Merdeka Timur 1A Jakarta 10110
Phone : (62-21) 3816367, 3816314, 3816339, 3816353, 3816217. Fax : 3455430, 3816348, 3507121
E-mail: opstanker@pertaminashipping.com

Statement of Temporary Stop


for Loading / Discharging

To whom it may concern


I, Master MT

stated that,

today ,

date

In port

at

hours local time, as requested by

the Loading Master,Mr.

,to temporary stop

discharging/ loading cargo from

hours local time,

until

hours local time.

due to :

Kindly sign and return the copy of this letter of acknowledgement.

Loading Master

Port of

Date

:
Master / Duty Officer

...

PT PERTAMINA (PERSERO)
SHIPPING MARKETING & TRADING DIRECTORATE
TH

SHIPPING OPERATION DIVISION, HEAD OFFICE 19 Floor, Jln. Merdeka Timur 1A Jakarta 10110
Phone : (62-21) 3816367, 3816314, 3816339, 3816353, 3816217. Fax : 3455430, 3816348, 3507121
E-mail: opstanker@pertaminashipping.com

TANKER TIME SHEET


Vessel Name
Flag
Master
GRT
DWT

:
:
:
:
:

Port of
Date
Voy No.
Last Port
B/L No.

STATEMENT OF ACTIVITY

DATE

Actual Time Arrived


Anchor at Outer Bar
Pilot On Board
Anchor Up
Anchor at Inner Anchorage
Free Pratique Granted
Pilot On Board
Anchor Up
NOR Tendered
NOR Accepted
First Line to Shore
All Made Fasted
Cargo Hose Connected
Commenced Ballast / Deballast
Completed Ballast / Deballast
Commenced Load / Disch (1)
Stopped Load / Disch order by Ship / Shore
Resume Load / Disch (2)
Stopped Load / Disch order by Ship / Shore
Resume Load / Disch (3)
Completed Load / Disch
Reduced Load / Disch rate order by Ship / Shore
Continues to Agreement Rate Load/ Disch (1)
Reduced Load / Disch rate order by Ship / Shore
Continues to Agreement Rate Load/ Disch (2)
Reduced Load / Disch rate order by Ship / Shore
Continues to Agreement Rate Load/ Disch (3)
Cargo Hose Disconnected
Ships Paper & Cargo Document on Board
Commenced Bunker
Completed Bunker
Cast Off
Anchor at Inner Anchorage
Pilot On Board
Anchor Up
Actual Time Departure / Sailed

:
:
:
:
:
HOUR

Next Port
ETA
Draft on
Arrival
Departure
TOTAL
PART
TIME

:
:
Fwd

Mean

Aft

:
:

Mtr
Mtr
REMARKS

B
A
B

A
C
A

A
/
C

C
B
Grade
MFO
MDO
HSD
FW
LO

A
A
B
A

SHORE FIGURE (BL / AR)

ROB Bunker (Metric Ton)


Arrv.
Repl.

Dept.

SHIP FIGURE (AL / BD)

GRADE
KL Obs
KL 15C
Bbls 60F
LT
MT
TOTAL TIME FOR :
Explanation of Delay :
From :
From :
From :

SHIP (A) :
To :
To :
To :

PT PERTAMINA (PERSERO)
Representative

AGENT (B) :

SHORE (C) :

:
:
:

MT/ TT
MASTER

PORT TIME
LAYTIME USED
LAYTIME ALLOWED
EXCESS TIME

HRS
HRS
HRS
HRS

PT PERTAMINA (PERSERO)
SHIPPING MARKETING & TRADING DIRECTORATE
TH

SHIPPING OPERATION DIVISION, HEAD OFFICE 19 Floor, Jln. Merdeka Timur 1A Jakarta 10110
Phone : (62-21) 3816367, 3816314, 3816339, 3816353, 3816217. Fax : 3455430, 3816348, 3507121
E-mail: opstanker@pertaminashipping.com

ULLAGE / SOUNDING - REPORT


M/T

VOYAGE

DATE

PORT

DRAFT

Mtr

Mtr

Mtr

ULLAGES /
*
SOUND
(CM)

TANK NO

OBSERVED
DENSITY
TEMP( C)
o
C
o

15

TEMP
o
CARGO ( C)

GRADE

REMARKS

1
2
3
PORT

CENTER

STBS

4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7

Note: If any compartement used for ballast tank or empty, must be explained in the remarks column

.
CHIEF OFFICER

choose one of two