DOCUMENT COMPLETION CHECK LIST

for TSSR DESIGN REVIEW

Site Name : NUMPAKCES TRENGGALEK

Indosat Site ID :

CLIENT SITE ID : JAW-JI-TRK-4072

SITE COORDINATE : LAT: '-8,179472 LONG: 111,5959

SITE ADDRESS : Klangsur, Dongko, Kabupaten Trenggalek, Jawa Timur 66363, Indonesia

No Description OK NOK NA

1 Cover

2 Berita Acara Survey Form

3 List of Existing Antenna & Proposed Antenna

4 RBS Foundation Layout Drawing

5 Antenna Placement Layout Drawing

6 Foto of RBS Placement Plan

7 Foto of Antenna Placement Plan

…………… , …………………

Submitted by, Checked by,

PT. HUAWEI TECH INVESTMENT PT. INDOSAT

(-----------------------------------------------) (------------------------------------------------)
 PROPOSED SITE COLLOCATION SUMMARY
FOR
COLO SHARED INFRASTRUCTURE

SITE NAME ISAT

NUMPAKCES TRENGGALEK
INDOSAT SITE ID

CLIENT SITE ID JAW-JI-TRK-4072

SITE COORDINATE LAT: -8,179472 LONG: 111,5959

SITE ADDRESS Klangsur, Dongko, Kabupaten Trenggalek, Jawa Timur 66363, Indonesia

Other Licensed Operator

Client Name PT. XL AXIATA, TBK

Prepared by PT. HUAWEI TECH INVESTMENT

Survey date 11-Dec-20

 RF

List of Existing Antenna & Proposed Antenna

for TSSR DESIGN REVIEW

Site Name : NUMPAKCES TRENGGALEK

Indosat Site ID :
CLIENT SITE ID : JAW-JI-TRK-4072

I. Existing Antennas

Size / Diameter Qty Height Azimuth

Description Remarks
(m) (pcs) (m) (°)
MW 1.8 1 49 180 XL
MW 0.6 1 23 250 XL

II. Proposed Antennas

Size Weight Inc Qty Feeder

Height Indosat
Description Type /Diameter Mounting (pc Azimuth (°) Diameter
(m) Recommendation
(m) Bracket (Kg) s) (inch)
46
RF 3 60/150/270

RRU 6 46

MW

III. Proposed BTS

BTS Type Dimension (m2) Indosat Recommandation
Outdoor / Indoor 5x1

…………… , …………………

Prepared by, Approved by,

PT. HUAWEI TECH INVESTMENT PT. INDOSAT

(-----------------------------------------------) (------------------------------------------------)
 PHOTOGRAPH DOCUMENTARY
Site No. : Project : Mini CME XL Project
Site Name : Location :
NUMPAKCES TRENGGALEK
Visit Date : 11-Dec-20
Prepared by : PT. HUAWEI TECH INVESTMENT
Surveyor : PT. PERSONEL ALIH DAYA

Proposed RBS
 PHOTOGRAPH DOCUMENTARY
Site No. : JAW-JI-TRK-4072 Project : Mini CME XL Project
Site Name : Location :
NUMPAKCES TRENGGALEK
Visit Date : 11-Dec-20
Prepared by : PT. HUAWEI TECH INVESTMENT
Surveyor : PT. PERSONEL ALIH DAYA

Proposed Antenna
Proposed Antenna
 REQUEST FOR APPROVAL
(Tower Rental Project)

Date :
SITE ID SITE INFO PROVIDE REMARK
SITE ID XL: JAW-JI-TRK-4072 RNP
SITE ID ISAT : 0 RF : 46m, azimuth :
SITE NAME XL : NUMPAKCES TRENGGALEK Location Photograph
TNP
Address: NE HEIGHT NE DIAMETER AZIMUTH FE SITE ID

FE HEIGHT FE DIAMETER AZIMUTH FREQUENCY

Klangsur, Dongko, Kabupaten Trenggalek, Jawa Timur 66363, Indonesia
Search Site Report
CIVIL 03/09/20
Foundation 5m x1 m
Tower Height : 50 m
Tower Type : Greenfield Power : 09/09/20
LOI PLN 13.2 Kva
Candidate Proposed Coordinate
LATITUDE : 0
LONGITUDE : 112.246437 Property Document
BSS 03/09/20

Prepared by,
PT. HUAWEI TECH INVESTMENT
NAME :
Date :
 CHECKLIST APPROVAL PROPOSAL

Date Of Issue : PERANGKAT JUMLAH SPESIFIKASI DATA TEKNIS REMARKS

Tower Owner : XL-AXIATA Ketinggian
Site ID Opetaror : 0 Azimuth 1 (°)
Site Name Operator : NUMPAKCES TRENGGALEK ANTENNA Azimuth 2 (°)
RND
Site ID XL : JAW-JI-TRK-4072 Azimuth 3 (°)
Site Nama XL : Feeder (") OPTIC
Site Address : Klangsur, Dongko, Kabupaten Trenggalek, RBS TYPE INDOOR /OUTFOOR OUTDOOR
Jawa Timur 66363, Indonesia
PLN CAPACITY
POWER
PLN + GENSET
CDC
Ukuran Shelter M
SHELTER INDOOR
Ukuran Pondasi M
Actual Coordinat Survey Ukuran Shelter M
SHELTER OUTDOOR
Longitude : 112.246437 Ukuran Pondasi M
CIVIL
Latitude : -8,179472 TOWER CAPACITY %
FAR END #1 (Site ID/Site Name) : …………………………………………………………………………………………..
FAR END #2 (Site ID/Site Name) : …………………………………………………………………………………………..
FAR END #3 (Site ID/Site Name) : …………………………………………………………………………………………..
Ketinggian 0
Diameter M
ANTENNA 1 Azimuth (°)
Frekuensi GHZ
Far End Site ID / Name
TRANSMISI Ketinggian MAGL
Diameter M
ANTENNA 2 Azimuth (°)
Frekuensi GHZ
Far End Site ID / Name

SITAC PIC RND POWER CIVIL TRANSMISSI

Name: Name: Name : Name :

Date : Date : Date : Date : Date :
PREPARED by : HUAWEI TECH INVESTMENT
 ENGINEERING SURVEY REPORT
Prepared by : Project :
PT.Huawei Tech Investment Tower Rental New Build / Collocation Existing

Document response / approved : Checked : Doc No : Revision : ………

(by provider)

Site No. : JAW-JI-TRK-4072

Site Name :
NUMPAKCES TRENGGALEK
Visit Date : December 11, 2020

I. GENERAL INFORMATION
Area : JAWA TIMUR
Site Address :
Klangsur, Dongko, Kabupaten Trenggalek, Jawa Timur 66363, Indonesia

Contact Person :

Phone Number :

Contact Person Address :

Access to site : ✘ Available Not Available Need a new additional access

Remarks : detail information (car entry or by walking or need ladder etc)

Access 24 hours/day : ✘ Yes Not identify hours : ………….to……………..

II. GEOGRAPHIC INFORMATION

NOM Coodinates LATITUDE : Long :

GPS Coordinates LATITUDE : 0 Long : 112.246437

✘
Map Datum : WGS 84
✘ Mark position on map ✘ A4 sketch from above

III. PHOTOGRAPH DOCUMENTARY

Photos taken ✘ GPS Photo 1 photos
✘ Surroundings tower (google maps) 1 captures & sketch
✘ 360 degree panorama, each 30 degree 12 photos
✘ Proposed site location 4 photos
✘ Site Access Maximum photos
✘ Obstacle objects - photos

Taken on ✘
Ground Exist. Tower Building Tree

Altitude 45 M.a.s.l (meter above sea level)

✘ Mark position on map ✘
A4 sketch from above

Page 1 of 7
 ENGINEERING SURVEY REPORT
Prepared by : Project :
PT.Huawei Tech Investment Tower Rental New Build / Collocation Existing

Document response / approved : Checked : Doc No : Revision : ………

(by provider)

IV. RADIO FREQUENCY ( RF ) DATA

RBS Antenna Height :
✘
RBS Antenna Direction : ✘ ✘

Surroundings :

OBSTACLE Direction (deg) Distance (m) Height (m)

ANTENNA TYPE V-POL X-POL

✘
RBS TYPE INDOOR OUTDOOR MODEL :

Note : Diisi oleh PIC RND XL berdasarkan info & data di SSR

IN GRID /OFF GRID : 0.00 M at ### 0

OTHER COMMENTS:

Note : Diisi oleh PIC RND XL

RF RECOMMENDATION : ✘
OK NOT OK

PIC BSS-RND Name :

Page 2 of 7
 ENGINEERING SURVEY REPORT
Prepared by : Project :
PT.Huawei Tech Investment Tower Rental New Build / Collocation Existing

Document response / approved : Checked : Doc No : Revision : ………

(by provider)

V. TRANSMISSION DATA
Prop.MW Antenna Height : ……...…. M
Diameter : ………….M Azimuth 21.55 …………..

SITE FACING PLAN (FE)

FACING SITES SITE ADDRESS LATITUDE LONGITUDE ALTITUDE (masl)

312A349G

TRM CONFIGURATION DATA (*)

FACING SITES DISTANCE (km) BEARING (degree) ANTENNA HEIGHT (m) DIAMETER (M)

(*) Diisi hanya untuk Project XL Own Build / oleh Vendor Sitac Regular

SURROUNDINGS (Including Panoramic Photograph)

OBSTACLE DIRECTION (deg) DISTANCE (km) HEIGHT (m)

OTHER COMMENTS :

TRM RECOMMENDATION : OK NOT OK

PIC TRM Name :
page 3 of 7
 ENGINEERING SURVEY REPORT
Prepared by : Project :
PT.Huawei Tech Investment Tower Rental New Build / Collocation Existing

Document response / approved : Checked : Doc No : Revision : ………

(by provider)

VI. CIVIL INFRASTRUCTURES DATA

SITE CATEGORY : ✘ Green Field Roof Top ✘

Existing

GREEN FIELD
General Topographi : ✘
Flat Swamp Slope Hilty

Soil General Classification : ✘

Normal Rocky Sandy Clay / Muld

Obstruction ✘
No Trees Building ……………..

Site Improvement required : ✘

Clearing Stripping Cut / Fill Demolist existing

ACCESS TO SITE
Distance from public road : 20 Meter Width : 3 Meter
Type of pavement : Hotmix Asphalt ✘ Concrete Paving Block

Macadam Aggregate ✘ Soil ……………..

Length of private access : Meter Width : Meter

Type of pavement : Hotmix Asphalt ✘ Concrete Paving Block

Macadam Aggregate Soil ……………..

Improvement required : Bridge Pavement ✘ Other (Manual Hauling)

PROPOSED AREA TO BE ACQUIRED (GREEN FIELD) (*) ###

Lot Size : Prop. Pondation : 5Mx1M
Access To Site : 20 X 3 = 60 Meter (Distance from public road) ###
(*) Diisi hanya untuk Project XL Own Build / oleh Vendor Sitac Regular

ROOF TOP - BUILDING STRUCTURE

Height Structure Type : Stories ………………… number

Roof Top ………………… meter

Penthose ………………… meter

Other ………………… meter

Old of Building : 0 Years

Building Structure Type : Reinforcr Concrete Steel Other

Building Using : Home Office Mall/Shop School/hospital

Potential Obstacle When N/A

:
Construction or Operation Available

page 4 of 7
 ENGINEERING SURVEY REPORT
Prepared by : Project :
PT.Huawei Tech Investment Tower Rental New Build / Collocation Existing

Document response / approved : Checked : Doc No : Revision : ………

(by provider)

ROOF TOP ACCESS

Access for Crane : Yes No
Stairway available : Yes No

- Dimension : m wide X m height

Passenger Lift : Yes No

- Capacity : ………… persons, from ……….. Trough ……………Floor

Material Lift : Yes No

- Capacity : ………… kg, from ……………. Trough ……………Floor

- Dimension : ………… m wide …………… m height

Ladder Yes No

- Dimension m Wide m Depth m Height

Potential Obstacle for Material

:
Equipment delivery

ADDITIONAL SUPPORTING STRUCTURE REQUIRED (*)

Beam : …………………. m length

Access Ladder : …………………. m length ……………. m wide Other : ………………..

(*) Diisi hanya untuk Project XL Own Build / oleh Vendor Sitac Regular

GROUNDING and LIGHTNING PROTECTION SYSTEM in BUILDING

Is grounding system available ? : No ✘ Yes Type and size :
Is it possible to use ? : No ✘
Yes

Is lightning protect available ? : No ✘ Yes Type and size :

Is it possible to use ? : No ✘
Yes

SHAFT and CABLE ROUTING

Is cable shaft available ? : ✘ Yes ✘ No

Routing cables/feeder : Tray Clamped Other : …………………

: length : …………………. M (including Routing Drawing)

PROPOSED AREA TO BE ACQUIRED (ROOF TOP) (*)

Lot Size : Rent Area : ..………….. Meter X ……………. Meter = ……….. Meter²

Access To Site : …………… Meter X ……………. Meter = ……….. Meter²

(*) Diisi hanya untuk Project XL Own Build / oleh Vendor Sitac Regular
page 5 of 7
 ENGINEERING SURVEY REPORT
Prepared by : Project :
PT.Huawei Tech Investment Tower Rental New Build / Collocation Existing

Document response / approved : Checked : Doc No : Revision : ………

(by provider)

TOWER DATA
Tower Height : 50 M ✘
From Ground Level From Roop Top Level

Tower Type : ✘
Self Supporting Tower Monopole/Single Pole
: Guyed Tower Three Camouflage

LEASING & PERMIT INFORMATION (*)

Lease Space : L 5 Meter X W 1 Meter X H…………… Estimated Rent ?

Can the site be Leased ? : ✘ Yes No

Can the site be Permitted ? : ✘

Yes No

(*) Diisi hanya untuk Project XL Own Build / oleh Vendor Sitac Regular

OTHER COMMENTS

Propose BTS for flood area

Flood Level +80 cm
Need Manual Haulling for material, due to access limitless

CIVIL RECOMMENDATION : OK NOT OK

PIC Civil Eng Name :
page 6 of 7
 ENGINEERING SURVEY REPORT
Prepared by : Project :
PT.Huawei Tech Investment Tower Rental New Build / Collocation Existing

Document response / approved : Checked : Doc No : Revision : ………

(by provider)

VII. POWER & ELECTRICITY

POWER SOURCE
Power Availability (PLN) For XL ✘
Available Not Available Capacity : 6.6 KVA

Distance From Existing PLN Pole : 5 meter nearest Traffo 150 m

Provided by building / PLN, Capacity : ... KVA ( FOR ROOF TOP SITE)

Additional facilities required (*) : ✘

Poles Cable Transformer Other

(*) Diisi hanya untuk Project XL Own Build / oleh Vendor Sitac Regular

OTHER COMMENTS:

POWER RECOMMENDATION : OK NOT OK

PIC Power Eng Name :

page 7 of 7

VII. ATTACHMENT

DOCUMENT INDICATION
✘
Photo GPS Photos
✘
Surroundings tower (radius 200 m) Google maps & Sketch
✘
360 degree panorama, each 30 degree Photos
✘
Site situation, access, existing facilities, etc Photos & Sketch
✘
Obstacle objects & near field obstruction Photos
✘
Existing facing sites Photos & Sketch
✘
Proposed site & Area Photos & Sketch
✘
Actual centerline, North on sketch Sketch
✘
Location and size of column and beam, existing and additional Photos & Sketch
✘
Proposed Location and Shelter, Tower, AC, Power meter, etc Photos & Sketch
✘
Proposed routing of cables (co-axial, power, grounding, lightening conductor) Photos & Sketch
✘
Antenna type, location, level and direction, present, future Sketch
✘
Site Outline Drawing Hard Copy
 PHOTOGRAPH DOCUMENTARY
Site No. : JAW-JI-TRK-4072 Project : Mini CME XL Project
Klangsur, Dongko, Kabupaten
Site Name : Location : Trenggalek, Jawa Timur 66363,
NUMPAKCES TRENGGALEK Indonesia
Visit Date : 11-Dec-20
Prepared by : PT. HUAWEI TECH INVESTMENT
Surveyor : PT. PERSONEL ALIH DAYA

GPS
 PHOTOGRAPH DOCUMENTARY
Site No. : JAW-JI-TRK-4072 Project : Mini CME XL Project

Jl. Kuin Cerucuk 43, Kuin Cerucuk, Kec.

Site Name : Location : Banjarmasin Bar., Kota Banjarmasin,
NUMPAKCES TRENGGALEK Kalimantan Selatan 70127, Indonesia

Visit Date : 11-Dec-20

Prepared by : PT. HUAWEI TECH INVESTMENT
Surveyor : PT. PERSONEL ALIH DAY

GPS Coordinates : Longitude :

Nominal : Latitude : -8,179472 Longitude :
Candidate : Latitude : -8,179472 111,5959
Distance candidate to nominal: 0 M 111,5959
Jl. Kuin Cerucuk 43, Kuin Cerucuk, Kec.
Banjarmasin Bar., Kota Banjarmasin,
Kalimantan Selatan 70127, Indonesia

PT. HUAWEI TECH INVESTMENT

 PHOTOGRAPH DOCUMENTARY
Site No. : JAW-JI-TRK-4072 Project : Mini CME XL Project
Klangsur, Dongko, Kabupaten
Site Name : Location : Trenggalek, Jawa Timur 66363,
NUMPAKCES TRENGGALEK Indonesia
Visit Date : 11-Dec-20
Prepared by : PT. HUAWEI TECH INVESTMENT
Surveyor : PT. PERSONEL ALIH DAYA

Panoramic 0o Panoramic 30o

 PHOTOGRAPH DOCUMENTARY
Site No. : JAW-JI-TRK-4072 Project : Mini CME XL Project
Klangsur, Dongko, Kabupaten
Site Name : Location : Trenggalek, Jawa Timur 66363,
NUMPAKCES TRENGGALEK Indonesia
Visit Date : 11-Dec-20
Prepared by : PT. HUAWEI TECH INVESTMENT
Surveyor : PT. PERSONEL ALIH DAYA

Panoramic 60o Panoramic 90o

 PHOTOGRAPH DOCUMENTARY
Site No. : JAW-JI-TRK-4072 Project : Mini CME XL Project
Klangsur, Dongko, Kabupaten
Site Name : Location : Trenggalek, Jawa Timur 66363,
NUMPAKCES TRENGGALEK Indonesia
Visit Date : 11-Dec-20
Prepared by : PT. HUAWEI TECH INVESTMENT
Surveyor : PT. PERSONEL ALIH DAYA

Panoramic 120o Panoramic 150o

 PHOTOGRAPH DOCUMENTARY
Site No. : JAW-JI-TRK-4072 Project : Mini CME XL Project
Klangsur, Dongko, Kabupaten
Site Name : Location : Trenggalek, Jawa Timur 66363,
NUMPAKCES TRENGGALEK Indonesia
Visit Date : 11-Dec-20
Prepared by : PT. HUAWEI TECH INVESTMENT
Surveyor : PT. PERSONEL ALIH DAYA

Panoramic 180o Panoramic 210o

 PHOTOGRAPH DOCUMENTARY
Site No. : JAW-JI-TRK-4072 Project : Mini CME XL Project
Klangsur, Dongko, Kabupaten
Site Name : Location : Trenggalek, Jawa Timur 66363,
NUMPAKCES TRENGGALEK Indonesia
Visit Date : 11-Dec-20
Prepared by : PT. HUAWEI TECH INVESTMENT
Surveyor : PT. PERSONEL ALIH DAYA

Panoramic 240o Panoramic 270o

 PHOTOGRAPH DOCUMENTARY
Site No. : JAW-JI-TRK-4072 Project : Mini CME XL Project
Klangsur, Dongko, Kabupaten
Site Name : Location : Trenggalek, Jawa Timur 66363,
NUMPAKCES TRENGGALEK Indonesia
Visit Date : 11-Dec-20
Prepared by : PT. HUAWEI TECH INVESTMENT
Surveyor : PT. PERSONEL ALIH DAYA

Panoramic 300o Panoramic 330o

 PHOTOGRAPH DOCUMENTARY
Site No. : JAW-JI-TRK-4072 Project : Mini CME XL Project
Klangsur, Dongko, Kabupaten
Site Name : Location : Trenggalek, Jawa Timur 66363,
NUMPAKCES TRENGGALEK Indonesia
Visit Date : 11-Dec-20
Prepared by : PT. HUAWEI TECH INVESTMENT
Surveyor : PT. PERSONEL ALIH DAYA

Panoramic 100o

Panoramic 270o

Panoramic 330o
Panoramic 330o
 PHOTOGRAPH DOCUMENTARY
Site No. : JAW-JI-TRK-4072 Project : Mini CME XL Project
Klangsur, Dongko, Kabupaten
Site Name : Location : Trenggalek, Jawa Timur 66363,
NUMPAKCES TRENGGALEK Indonesia
Visit Date : 11-Dec-20
Prepared by : PT. HUAWEI TECH INVESTMENT
Surveyor : PT. PERSONEL ALIH DAYA

Tampak Atas Bagian Depan Site Tampak Atas Bagian Belakang Site
 PHOTOGRAPH DOCUMENTARY
Site No. : JAW-JI-TRK-4072 Project : Mini CME XL Project

Klangsur, Dongko, Kabupaten

Site Name : Location : Trenggalek, Jawa Timur 66363,
NUMPAKCES TRENGGALEK Indonesia

Visit Date : 11-Dec-20

Prepared by : PT. HUAWEI TECH INVESTMENT
Surveyor : PT. PERSONEL ALIH DAYA

Tampak Atas Bagian Kiri Site Tampak Atas Bagian Kanan Site
 PHOTOGRAPH DOCUMENTARY
Site No. : JAW-JI-TRK-4072 Project : Mini CME XL Project

Klangsur, Dongko, Kabupaten

Site Name : Location : Trenggalek, Jawa Timur 66363,
NUMPAKCES TRENGGALEK Indonesia

Visit Date : 11-Dec-20

Prepared by : PT. HUAWEI TECH INVESTMENT
Surveyor : PT. PERSONEL ALIH DAYA

SITE ACCESS TO SITE

SITE ACCESS TO SITE

* Need add manual hauling for material due to access limitless, ± 35 meter
 PHOTOGRAPH DOCUMENTARY
Site No. : JAW-JI-TRK-4072 Project : Mini CME XL Project
Klangsur, Dongko, Kabupaten
Site Name : Location : Trenggalek, Jawa Timur 66363,
NUMPAKCES TRENGGALEK Indonesia
Visit Date : 11-Dec-20
Prepared by : PT. HUAWEI TECH INVESTMENT
Surveyor : PT. PERSONEL ALIH DAYA

SITE ACCESS TO SITE

 PHOTOGRAPH DOCUMENTARY
Site No. : JAW-JI-TRK-4072 Project : Mini CME XL Project
Klangsur, Dongko, Kabupaten
Site Name : Location : Trenggalek, Jawa Timur 66363,
NUMPAKCES TRENGGALEK Indonesia
Visit Date : 11-Dec-20
Prepared by : PT. HUAWEI TECH INVESTMENT
Surveyor : PT. PERSONEL ALIH DAYA

POLE PLN

TRAFO PLN
 PHOTOGRAPH DOCUMENTARY
Site No. : JAW-JI-TRK-4072 Project : Mini CME XL Project
Klangsur, Dongko, Kabupaten
Site Name : Location : Trenggalek, Jawa Timur 66363,
NUMPAKCES TRENGGALEK Indonesia
Visit Date : 11-Dec-20
Prepared by : PT. HUAWEI TECH INVESTMENT
Surveyor : PT. PERSONEL ALIH DAYA

SITE SITUATION 1

SITE SITUATION 2
As to As (tower width leg to leg) - process

anchor measurement

steel baseplate measurement thickness

one of leg member measurement - thickness
As to As (tower width leg to leg) - detail

steel baseplate measurement width

one of leg member measurement - width