FOR NEAR COASTAL VOYAGE

VESSEL NAME

LCT ARMANSYA FORTUNA 07

CONTRACT NUMBER

40004420001465A
17-May-16

DATE

MARINE CREW MATRIX COMPETENCIES DECLARATION FORM

I, as the Contract Manager / Representative of PT.SAMUDERA ENERGI TANGGUH For Service Contract No. 40004420001465A hereby declare that personnel listed below have been assessed and confirms where meet with the Company's Standard and/Or STCW '95 of competency, safety behavior and health to work at BP Tangguh. All listed personnel have been explained in
regards to scope of work, execution plan, risk assessment, operating procedure, tools/equipment in use and the emergency procedure.
I am fully responsible for the validity of information given hereby and will ensure the compliance of this declaration.

BP Marine AsPac ADDITIONAL REQUIREMENTS TO CMID / OVID

Name

Position

Years Experience
on
Similiar vessel
(min 5 years)

Seaman
Book

Certificate of
Competency
(ANT/ATT)

Certificate
Number

Endorseme
nt
License

Years - Month

No & Exp date

Class &
Issued date

10 digit

ANT III
ANT IV
ANT IV

Proficiency Certificate (STCW' 95) with validity max. 5 years

Other Certificate
MCU

Lifting &
Rigger's Cert

SSO

ISM Code

TF
(If Tanker)

OT
BRM / ERM
(If Tanker)

Expired date

Expired date

Expired date

Expired date

Expired date

Expired date

Expired date

29-10-15
14-12-13
19-12-13

07-05-17
08-05-17
07-05-17

16-10-15
07-08-14
28-10-15

25-03-02

BST

SCRB

MFA

MC

AFF

RADAR

ARPA
(If
installed)

GMDSS

GOC / ORU

Expired date

Expired date

Expired date

Expired date

Expired date

Expired date

Expired date

Expired date

Expired date

6200 023820
6200 087001
6200 074467

22-12-15
06-07-11
25-03-16

09-12-15
11-02-16
23-12-15

09-11-15
11-01-16
22-10-15

09-11-15
11-01-16
26-10-15

09-11-15
25-07-10
27-10-15

19-10-15
11-01-16
23-10-15

09-11-15
11-11-10
28-01-15

09-11-15
16-11-10
16-02-16

11-12-15
18-06-10
27-11-15

Marzuki Ramli
Ismail
Syariffudin

Master
Chief Officer
2nd Officer
3rd Officer

30
23
9

W 059528
C 036297
E 065841

Romi Patandianan

Chief Engineer

B 015306

ATT III

6200 542629

23-04-12

22-02-12

02-03-12

08-03-12

16-01-12

16-03-12

08-05-17

28-01-12

29-03-12

Achmad Deni Ladiku

2nd Engineer

C 001917

ATT IV

6201 290606

14-3-16

09-12-15

04-04-13

10-04-13

16-11-15

08-04-13

07-05-17

02-11-15

22-04-13

Lahmuddin

3rd Engineer

21

D 058988

ATT V

6200 515177

02-10-12

18-10-12

05-10-15

05-10-12

15-10-12

07-05-17

16-02-13

21-02-13

07-05-17

Expired date

ECDIS

CT
(If Tanker)

CM

CMHB

Expired date

Expired date

Expired date

Expired date

12-11-12

30-04-13

Bosun
Adi Pujono

AB 1

C 084348

ANT D

6200 256698

12-09-07

Abdul Kadir

AB 2

B 062984

R. DECK

6202 0156973

17-04-13

Sade

AB 3

18

B 042720

R. DECK

6200 0849513

09-02-15

09-12-16

Basir

B 062967

R. ENGINE

6202 0106473

05-06-12

11-11-11

Y 066744

ANT D

6201 312294

07-12-13

Yandri Limbong

Oiler 1
Oiler 2
Oiler 3
Deck Hand
Engine Hand
Cook
Messboy
Deck Cadet
Engine Cadet

D 058966

CADET/E

62115011730

Doni Triwibawa Prakasa

Marine Coordinator

Rusdi Umar

Ricky Mambrasar

Marine Coordinator

0.8

B000962
W048937

ANT-II
ANT III

620007714

03-05-15
13-04-09

6200395793N
6200395793N30316 30316

13-04-09

30-09-15

07-05-15
13-04-09

13-02-12

13-04-09

09-06-15

06-05-15
13-04-09

13-04-09

21-05-15

08-05-17

29-11-10 29-11-10
07-07-15

26-06-15

13-04-09

15-2-09

4030904
03-06-15

404090
7020

13-04-09

18-04-16

During the project OR operation's execution, the listed personnel will comply with the following requirements to ensure all activities can be safely completed.
1. Adherence to the whole process of Permit To Work (PTW), Operating Procedures, HSE requirments, Good Safety behavior practices and accept all consuequences of procedure / regulation violation.
2. Stop the job and immediately to report to Master or Supervisor for any further risk assessment for any unsafe conditions or inconsistencies with the plan as outlined in the PTW (i.e. changing the plan or scope of work or sequence, tools / equipment break down, uncertain or in doubt on executing the job, presence of new hazards).
3. Aware of the hazard, write them down on Level 1 or L2RA and implement the mitigation during work planning, preparation, execution, usage of equipment include other chemical and other hazardous materials (refer to MSDS) if any.

Declared by,

Endorsed by,

Mahmud Tarmizi Amir

President Director

Muchtar Harris
Contract Accountable Manager