Service
Report
Berita Acara
Report to Customer
Rentokil Indonesia (RI-JK-OS-230-SE-F-8.5-06)
Ref:142143_20230127162612
A. CUSTOMER INFORMATION
Purpose of Treatment Routine Shared Type of Premise Hospitals
Account Number 700022169 Type of Pests Covered Qty Freq
Contract Number 50051177/1 General Pest Plus
: Ants - Other, Cockroaches - Other, Flies, Mosquito, Rodents 0 48
Type of Premise Hospitals (GPP)
Customer Name RS SEPATAN MULIA Cat Control
0 48
Contact Name IBU NOVA : (CATC)
Fogging (Oil Based)
Contact Number +622159371801 0 48
: (FOG)
Address (Site of application) RS SEPATAN MULIA
JL. RAYA PAKUHAJI RT 02 RW
01
SEPATAN
TANGERANG
BANTEN
15520
Site Risk Assessment
Terdapat Anak-anak/Orang Tua/Orang Cacat/Keramaian : AREA DALAM Terdapat kendaraan/forklift/mesin pengangkat : PARKIR Bahan kimia/gas/debu/uap
: AREA LUAR, AREA DALAM Mengangkat/mengangkut : AREA LUAR, AREA DALAM Adanya penghisap udara pada sistem ventilasi : AREA DALAM
B. APPLICATOR’S INFORMATION C. CUSTOMER’S SIGNATURE/COMPANY STAMP
I declare the information below is true and
I acknowledge receipt of the report below:
correct:
Signature: Signature:
FIKRI BAMBANG IRAWAN
Name Name adi
FIKRI BAMBANG IRAWAN
License No. Date 27-01-2023 13:36
Date 27-01-2023 13:36
Time In 13:36
Time Out 16:26
Name of other Applicators:
D. PESTICIDES APPLIED
Active Ingredient Trade Name Class Method of Total Area Total
(Conc. Diluted Solution Applied (%)) (Conc. Diluted Solution Applied (%)) Application Treated Qty Used
Lem Tikus Tube (GPP) Monitoring / Trapping 3 Tube
Area Pesticide Applied
Cypermethrin Smash 100EC (GPP) Spraying 100 ml
Area Pesticide Applied
Brodifacoum Talon 0.005 BB (GPP) Baiting 120 gram
Area Pesticide Applied
Cypermethrin Smash 100EC (GPP) Cold fogging 200 ml
Area Pesticide Applied
Cypermethrin Smash 100EC (FOG) Thermal fogging 100 ml
Area Pesticide Applied
1/3
Brodifacoum Talon 0.005 BB (GPP) Baiting 8 gram
Area Pesticide Applied
Brodifacoum Talon 0.005 BB (GPP) Baiting 8 gram
Area Pesticide Applied
Lem Tikus Tube (GPP) Monitoring / Trapping 0.25 Tube
Area Pesticide Applied
Lem Tikus Tube (GPP) Monitoring / Trapping 0.25 Tube
Area Pesticide Applied
Luminos 1 Glue 011 (GPP) Monitoring / Trapping 1 Unit
Area Pesticide Applied
Luminos 1 Glue 011 (GPP) Monitoring / Trapping 1 Unit
Area Pesticide Applied
Luminos 1 Glue 011 (GPP) Monitoring / Trapping 1 Unit
Area Pesticide Applied
Luminos 1 Glue 011 (GPP) Monitoring / Trapping 1 Unit
Area Pesticide Applied
Luminos 1 Glue 011 (GPP) Monitoring / Trapping 1 Unit
Area Pesticide Applied
Luminos 1 Glue 011 (GPP) Monitoring / Trapping 1 Unit
Area Pesticide Applied
Cypermethrin Smash 100EC (GPP) Spraying 100 ml
Area Pesticide Applied
Cypermethrin Smash 100EC (FOG) Thermal fogging 100 ml
Area Pesticide Applied
Cypermethrin Smash 100EC (GPP) Cold fogging 200 ml
Area Pesticide Applied
E. PEST STATUS
Pest Level Location Found Remarks
Flying Insect Other Medium - 24 Internal
Building: RS SEPATAN MULIA, Floor: 1st Floor, Zone: 3rd Line Office, Location Found: I4. 2 LUMNIA
Houseflies Low - 5 Internal
Building: RS SEPATAN MULIA, Floor: 1st Floor, Zone: 3rd Line Office, Location Found: I4. 2 LUMNIA
Mosquito Low - 17 Internal
Building: RS SEPATAN MULIA, Floor: 1st Floor, Zone: 3rd Line Office, Location Found: I4. 2 LUMNIA
Flying Insect Other Medium - 21 Internal
Building: RS SEPATAN MULIA, Floor: 1st Floor, Zone: 3rd Line Office, Location Found: I4. 4 LUMNIA
Mosquito Low - 13 Internal
Building: RS SEPATAN MULIA, Floor: 1st Floor, Zone: 3rd Line Office, Location Found: I4. 4 LUMNIA
Flying Insect Other Low - 17 Internal
Building: RS SEPATAN MULIA, Floor: 1st Floor, Zone: 3rd Line Office, Location Found: I4. 6 LUMNIA
Mosquito Low - 19 Internal
Building: RS SEPATAN MULIA, Floor: 1st Floor, Zone: 3rd Line Office, Location Found: I4. 6 LUMNIA
Flying Insect Other Low - 18 Internal
Building: RS SEPATAN MULIA, Floor: 1st Floor, Zone: 3rd Line Office, Location Found: I4. 1 LUMNIA
Houseflies Low - 5 Internal
Building: RS SEPATAN MULIA, Floor: 1st Floor, Zone: 3rd Line Office, Location Found: I4. 1 LUMNIA
Mosquito Low - 14 Internal
Building: RS SEPATAN MULIA, Floor: 1st Floor, Zone: 3rd Line Office, Location Found: I4. 1 LUMNIA
Flying Insect Other Medium - 26 Internal
Building: RS SEPATAN MULIA, Floor: 1st Floor, Zone: 3rd Line Office, Location Found: I4. 5 LUMNIA
Flying Insect Other Medium - 26 Internal
2/3
Building: RS SEPATAN MULIA, Floor: 1st Floor, Zone: 3rd Line Office, Location Found: I4. 5 LUMNIA
Houseflies Low - 4 Internal
Building: RS SEPATAN MULIA, Floor: 1st Floor, Zone: 3rd Line Office, Location Found: I4. 5 LUMNIA
Mosquito Low - 18 Internal
Building: RS SEPATAN MULIA, Floor: 1st Floor, Zone: 3rd Line Office, Location Found: I4. 5 LUMNIA
Flying Insect Other Medium - 27 Internal
Building: RS SEPATAN MULIA, Floor: 1st Floor, Zone: 3rd Line Office, Location Found: I4. 3 LUMNIA
Mosquito Low - 18 Internal
Building: RS SEPATAN MULIA, Floor: 1st Floor, Zone: 3rd Line Office, Location Found: I4. 3 LUMNIA
F. RECOMMENDATIONS BY RENTOKIL INITIAL
Type Recommendations Priority
Stacking (GPP) lakukan pembersihan area dekat parkir motor,masih adany sisa2 material proyek. Low
G. SERVICE VISIT NOTES
Product (s) Visit Notes
Fogging (Oil Based) - 48
Cat Control - 48
General Pest Plus - 48
Rentokil Indonesia Komplek Pergudangan Multiguna, Duta Indah Iconic, Blok C No.37, Jl. M H Thamrin, Cikokol, Tangerang, 15117
t +622129866707/706 f e [email protected] w www.rentokil.co.id p myRentokil
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