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TECHNICAL SITE SURVEY ACQUISITION REPORT (TSSAR)

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Visit Date : Region : Site ID : 02200604 Alt : A

Surveyor : Area : Site Name :

1. GENERAL INFORMATION Type of Site: Roof Top/Greenfield/Existing/Swap/Backbone/BSC

Project Name Contractor

Address (RT/RW, Kelurahan, Kecamatan, Kabupaten, Post Code)

Owner’s Name Ibu Lena

Telephone / Fax Mobile Phone 0852 784 85 123

Contac Person Name

Telephone/Fax Mobile Phone

Type of Ownership Single owner Corporation Other

Government Community Partnership

Surroundings

Perumahan Pekantoran Jalan raya Persawahan

Pabrik Pasar Hotel Mall

Others = Restaurant

Access To site Available Not Available Need Additional

Access 24 hours Yes No, identify hours…………………………………………..

2. CIVIL & ELECTRICAL INFORMATION

Green field

General Topography Soil Classification Site Improvement

Flat Normal Clearing

Swamp Rocky Stripping

Slope Sandy Fill

Hilly Clay / Muld Demolish existing

Roof Top / Pole

Height of Building…………………….Meter Old of building…………………….Years

Building Structure Reinforce Concrete Steell Other…………….

Building Using Home/Office Mall Other…………….

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Equipment room/Shelter Permanent CKD Other

Existing Room Outdoor Shelter ………………………………….

Dimension = 3 x 1 (m)

Access Road

Use private Access Use Public Access

Length of private access = 35m. X 3m….. Length of public access = ………. X ……….

Access fit for Sedan/minibus/Truck/Big Truck (*) Yes No

Asphalt Hotmix Concrete Paving Block

Aggregate Soil Macadam Other…………..

Level of difficulties in construction Easy Moderate Normal Difficult

If Backfill is required on site, how much the volume (PxLxT) ?

Roof Top Access

Access for Crane Yes No

Stairway available Yes, Dimension ……. X ………. No

Material Lift Yes, Capacity …………… Kg No

Power Source (see pic on add form)

PLN, Distance Pole / Transformer : 60m… m Not Available, need Genset

Provided by Owner including Genset (*) Capacity :………KVA,……..Phase

Additional Required Poles (1) Transformer Cable (how……)

Is there any regular power OFF? Yes No

Duration PLN intentionally shutdown < 3 hours > 3 hours

Cable routingShaft cable Yes No

Proposed routing Tray Clamped Other…………..

3. ACQUISITION AND PERMIT INFORMATION

Land / Rooftop Area Length x Width

(m)15 m x 15 m Area (m2) 225 m2

Acquisition Type Lease 10 Years (min) Can be

extended

Yes

Buy No

LEA

SE

Total Lease Price Payment Method

Leasing Procedures Present of Notaris Without Notaris

Lease Price condition PPh…… Tax Included PPh ……. Tax Not Included

Notaris Fees Included Notaris Fees Not Included

Buy Price / m2

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BU

Y

Total Price

Buy Price conditions PPAT Fees Included PPAT Fees Not Included

BPHATB 5% Included BPHATB 5% Not Included

Is the price above the reference price ?

Yes No

Transaction terms PLN Power Included PLN Power Not Included

Land Ownership documents

Girik/Persil No.

Sertifikat No.

SPPT/PBB No.

Akte Jual-Beli No.

Lain-lain

Is the site located within 15 km from the airport Yes No

Site not in high criminal area (gambling preman…..etc) Yes No

Site not in forbidden area Yes No

Permits Required For ‘Ijin Mendirikan

RT/RW Tata Kota (RUTR) Military

Kelurahan Bapeda Community

Kecamatan Hub Tel Socialisation

Other :

Permits PossibilitiesGovernment Permits OK Not OK

Community Permits OK Not OK

Civil Recommendation OK NOT OK

Sitac Recommendation OK NOT OK

Other Comment : Prepared By : Cheked By :

4. RF AND TRANSMISSION INFORMATION

Proposed Tower Height : 60 m Plan Antenna Height : m Plan Antenna Type :

Nominal Coordinate Longitude Latitude :

Alternative Coordinate Longitude : Latitude :

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Distance from Nominal 22 m

Map Datum and level of GPS WGS 84

RBS Antenna Direction (deg) ..… 0 …… 0 ...… 0

Facing and Geographich Data

Facing Site Direction (deg) Obstacle Remarks of Obstacle Free

Free obstacle surrounding Yes No

Surroundings

Perumahan Pekantoran Jalan raya Persawahan

Pabrik Pasar Hotel Mall

Others = Restaurant

RF Recommendation OK NOT OK

TRF Recommendation OK NOT OK

Other Comment : Prepared By : Checked By :

5. OTHERS COMMENT

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6. ATTACHMENTS

Street Map (Scanned) Site situation, access, existing facilities Photos

Site Location Sketch & Photos Obstacle objects & near field obstruction Photos & Sketch

Site Layout Sketch Proposed Tower/Poles Location Photos

Rooftop Layout Sketch Proposed Shelter/ER Location Photos

Proposed Cable Trays Photos (co-axil, power, grounding,etc) Proposed Utilities Photos

Panoramic 3600 Photos (Rooftop site) Transmission link sketch

Distance from Nominal Coordinate if its Alternative Site(Mark here with an Alternatives Names “A”, B and “C”)

00

450

1350

1800

2250

2700

3150

Nominal Coordinate

50m

100m

150m 250m

500m900

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Obstacles: describe all obstructing obstacles within 500 meters, which are of a height equal to or higher than the site

Alt Azimuth Distance Height AGL Description

A

B

C

Site Map

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Site Layout Sketch (measurement)

Candidate coordinate candidate elevation distance from

NOM

Note: the existing PLN pole and NOM position must be drawn in the street map

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Site Green Field / Rooftop Layout Sketch

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PLAN VIEW AND SITE CONTOUR

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CROSS SECTION IS PRODUCED MIN 10M DISTANCE OUTSIDE OF THE SITE CANDIDATE THAT WILL BE PURCHASED OR RENT. IF ANY DIFFERENCE OF EVALUATION MORE THAN 3M OUT SIDE

OF THE 10M DISTANCE IT MUST BE DESCRIBE ON THE CROSS SECTION SKETCH

ACCESS CONDITION TO THE SITE

main access to site SECONDARY access to site

P x L : ……………………… P x L ………………………….

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TERTIARY access to site Planned access to site

P x L : …………………….. P x L : …………………………………………..

Can heavy truck access to location ? Yes No

Access road condition to location ?

Very Good Good Not So Bad Bad Very Bad

CONDITION OF THE SITE

FRONT VIEW RIGHT VIEW

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LEFT VIEW BACK VIEW

surrounding

ELECTRICAL AVAILABILITY

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Please insert the photo of nearest electrical pole here

ELECTRICAL AVAILABILITY

Pole PLN

CONDITION OF THE NOMINAL

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NOM

PANORAMIC PHOTO DOCUMENTATION

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0° 45°

90° 135°Remarks on surrounding situation from location :Perumahan dan perkantoran

PANORAMIC PHOTO DOCUMENTATION

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180° 225°

Remarks on surrounding situation from location :Perkantoran

270° 315°

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