P E M E R I N T A H K A B U P A T E N B O Y O L A L I DINAS PENANAMAN MODAL

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w w w . b p m p 2 t . b o v o l a l i k a b . g o . i d e m a i l : b p m p 2 t @ . b o y o l a l i k a b . g o . i d

P e r s e t u j u a n N o m o r T a n g g a l

K E P A L A D I N A S P E N A N A M A N M O D A L D A N

P E L A Y A N A N T E R P A D U S A T U P I N T U

EL. RUSDIJANTI HL. SH. P e m b i n a U t a m a M u d a

N I P : 1 9 6 0 0 5 3 0 1 9 8 8 0 2 2 0 0 2

D i i s i o l e h P e m o h o n

S U R A T P E R M O H O N A N I J I N U S A H A I N D U S T R I K E C I L / M E N E N G A H / B E S A R

( S P I S I U I K E C I L / M E N E N G A H / B E S A R , M E L A L U I T A H A P P E R S E T U J U A N P R I N S I P / T A N P A M E L A L U I T A H A P P E R S E T U J U A N

P R I N S I P / C A R A L A N G S U N G )

D I I S I H U R U F C E T A K

N o m o r : T a n g g a l :

Y a n g b e r t a n d a t a n g a n d i b a w a h i n i m e n g a j u k a n p e r m o h o n a n S u r a t I z i n U s a h a I n d u s t r i p u s a t

C a b a n g s e b a g a i m a n a d i m a k s u d p a d a P e r a t u r a n D a e r a h N o m o r T a h u n t e n t a n g

K e t e n t u a n d a n T a t a C a r a P e m b e r i a n S u r a t I j i n U s a h a I n d u s t r i s e b a g a i b e r i k u t :

I . Maksud Permohonan Ijin Memperoleh SIUI ( L i n g k a r i a n g k a y a n g d i m a k s u d ) 1 . S I U I B a r u

2 . P e n d a f t a r a n U l a n g S I U I

3 . P e m b a h a r u a n S I U I

K e p a d a Y t h : K e p a l a D i n a s P e n a n a m a n M o d a l D a n P e l a y a n a n T e r p a d u S a t u P i n t u K a b u p a t e n B o y o l a l i D i -

B O Y O L A L I

1 ) D i i s i o l e h D i n a s

-HJ«!!»i>-r

I I , . Status Perusahaan I I I . Identitas Perusahaan

1 . N a m a p e r u s a h a a n

2 . N a m a p e m i l i k / p e n a n g g u n g j a w a b

3 . B e n t u k p e r u s a h a a n

4 . A l a m a t p e r u s a h a a n

- J a l a n / l o r o n g ( g a n g

- D u k u h d a n R T / R W

- D e s a / K e l u r a h a n

- K e c a m a t a n

- T e l e p o n / F a x ^ '

5 . P e n d i d i k a n t e r a k h i r

6 . S t a t u s t e m p a t u s a h a

7 . N o m o r P o k o k W a j i b P a j a k ( N P W P )

8 . M e r k P e r u s a h a a n

9 . N a m a S u a m i / i s t r i ^ '

K e w a r g a n e g a r a a n

: T u n g g a l / P u s a t / C a b a n g

S D / S L I P / S L T A / D 3 / S I / S 2 / S 3 "

IV. Jika status perusahaan Pusat / Cabang, sebutkan.^'

1 . N a m a p e r u s a h a a n

2 . A l a m a t p e r u s a h a a n

3 . N a m a p e m i l i k / p e n a n g g u n g j a w a b

4 . A l a m a t p e m i l i k / p e n a n g g u n g j a w a b

5 . J e n i s p r o d u k s i / K L U I

6 . K o m o d i t i i n d u s t r i

7 . N o m o r / t a n g g a l l U I / T D I

V. Lokasi dan Luas tanah

1 . L o k a s i

a.

c.

L a h a n P e r u n t u k a n I n d u s t r i ( L P I )

D i l u a r K a w a s a n I n d u s t r i / K a w a s a n B e r i k a t

b .

d .

D i d a l a m K a w a s a n I n d u s t r i K a w a s a n B e r i k a t K o m p l e k s I n d u s t r i ( P I K / L I K )

2 . L u a s t a n a h ( m ^ )

2 ) C o r e t y a n g t i d a k p e r l u 3 ) J i k a K a n t o r C a b a n g l e b i h d a r i s a t u d i b u a t k a n l e m b a r t e r s e n d i r i

V I . Produksi, Mesin dan Peralatan, Bahan Baku dan Penolong a. P r o d u k s i

N o . J e n i s P r o d u k K a p a s i t a s T e r p a s a n g / T a h u n P r o d u k R i i l K e t e r a n g a n

b . M e s i n d a n P e r a l a t a n 1 ) M e s i n d a n p e r a l a t a n p r o d u k s i

N o J e n i s

M e s i n / P e r a l a t a n U t a m a

J u m l a h

K a p a s i t a s T e r p a s a n g

d a n S p e s i f i k a s i

M e r e k d a n T a h u n

P e m b u a t a n

N e g a r a A s a l

H a r g a * ) R p . 0 0 0 )

a. D a l a m N e g e r i

b . I m p o r ( e k s i m p o r )

* ) H a r g a I m p o r ( C & F ) , K u r s = M a t a u a n g a s i n g ( )

2 . M e s i n / P e r a l a t a n P e n g e n d a l i a n P e n c e m a r a n

N o J e n i s

M e s i n / P e r a l a t a n U t a m a

J u m l a h

K a p a s i t a s T e r p a s a n g

d a n S p e s i f i k a s i

M e r e k d a n T a h u n

P e m b u a t a n

N e g a r a A s a l

H a r g a * ) R p . 0 0 0 )

a. D a l a m N e g e r i

b . I m p o r ( e k s i m p o r )

C a t a t a n : J i k a t i d a k c u k u p d i b u a t k a n d a f t a r t e r s e n d i r i * ) H a r g a I m p o r ( C & F ) , K u r s = M a t a u a n g a s i n g ( )

2 ) C o r e t y a n g t i d a k p e r l u

c. B a h a n B a k u d a n P e n o l o n g y a n g d i g u n a k a n s e l a m a s e t a h u n 1 ) B a h a n B a k u ( d i g u n a k a n s e l a m a 1 t a h u n ) ^ -

N o . N a m a S p e s i f i k a s i J u m l a h S a t u a n N e g a r a A s a l

H a r g a * ) ( R p . 0 0 0 ) K e t e r a n g a n

a . B a h a n B a k u 1 ) D a l a m N e g e r i

2 ) I m p o r ( e k s i m p o r )

2 ) B a h a n P e n o l o n g

N o . N a m a S p e s i f i k a s i J u m l a h S a t u a n N e g a r a A s a l

H a r g a * ) ( R p . 0 0 0 )

K e t e r a n g a n

b . B a h a n P e n o l o n g 1 ) D a l a m N e g e r i

2 ) I m p o r ( e k s i m p o r )

* ) H a r g a I m p o r ( C & F ) , K u r s = M a t a u a n g a s i n g ( )

V I I . Jadwal waktu penyelesaian pembangunan

P a b r i k d a n S a r a n a P r o d u k s i :

1 . P e n y e l e s a i a n P e m b a n g u n a n P a b r i k

2 . P e n y e l e s a i a n P e m b a n g u n a n S a r a n a

P r o d u k s i

: B u l a n T a h u n .

: B u l a n T a h u n

V I I I . Nilai Investasi 1 . M o d a l T e t a p :

a. T a n a h b . B a n g u n a n • c. M e s i n / P e r a l a t a n d . D a n l a i n - l a i n

2 . M o d a l K e r j a a. B a h a n B a k u u n t u k b . U p a h c. D a n l a i n - l a i n

3 . S u m b e r P e m b i a y a a n a. M o d a l s e n d i r i b . P i n j a m a n

b u l a n

R p . R p . R p . R p .

R p . R p . R p .

R p . R p .

2 ) C o r e t y a n g t i d a k p e r l u

c. B a h a n B a k u d a n P e n o l o n g y a n g d i g u n a k a n s e l a m a s e t a h u n 1 ) B a h a n B a k u ( d i g u n a k a n s e l a m a 1 t a h u n )

N o . N a m a S p e s i f i k a s i J u m l a h S a t u a n N e g a r a A s a l

H a r g a * ) ( R p . 0 0 0 )

K e t e r a n g a n

a . B a h a n B a k u 1 ) D a l a m N e g e r i

2 ) I m p o r ( e k s i m p o r )

2 ) B a h a n P e n o l o n g

N o . N a m a S p e s i f i k a s i J u m l a h S a t u a n N e g a r a A s a l

H a r g a * ) ( R p . 0 0 0 )

K e t e r a n g a n

b . B a h a n P e n o l o n g 1 ) D a l a m N e g e r i

2 ) I m p o r ( e k s i m p o r )

) H a r g a I m p o r ( C & F ) , K u r s = M a t a u a n g a s i n g ( )

V I I . Jadwal waktu penyelesaian pembangunan

P a b r i k d a n S a r a n a P r o d u k s i :

1 . P e n y e l e s a i a n P e m b a n g u n a n P a b r i k : B u l a n T a h u n

2 . P e n y e l e s a i a n P e m b a n g u n a n S a r a n a : B u l a n T a h u n

P r o d u k s i

V I I I . Nilai Investasi 1 . M o d a l T e t a p :

a. T a n a h : R p . b . B a n g u n a n • : R p . c. M e s i n / P e r a l a t a n : R p . d . D a n l a i n - l a i n : R p .

2 . M o d a l K e r j a a. B a h a n B a k u u n t u k b u l a n : R p . b . U p a h : R p . c. D a n l a i n - l a i n ^ : R p .

3 . S u m b e r P e m b i a y a a n a. M o d a l s e n d i r i : R p . b . P i n j a m a n : R p -

2 ) C o r e t y a n g t i d a k p e r l u

IX. Tenaga Kerja 1 . P e n g g u n a a n T e n a g a K e r j a I n d o n e s i a :

a. T e n a g a A d m i n i s t r a s i L a k i - l a k i o r a n g

b . I e n a g a P r o d u k s i T 1 * 1 1 *

L a k i - l a k i o r a n g

c . T e n a g a P e m a s a r a n L a k i - l a k i o r a n g , W a n i t a o r a n g

P e n g g u n a a n T e n a g a A s i n g a . T e n a g a A d m i n i s t r a s i L a k i - l a k i o r a n g

b . T e n a g a P r o d u k s i L a k i - l a k i o r a n g

c . T e n a g a P e m a s a r a n L a k i - l a k i o r a n g , W a n i t a o r a n g d . N e g a r a A s a l

e. J a n g k a w a k t u t i n g g a l d i I n d o n e s i a

X. Pemasaran 1 . D a l a m N e g e r i : %

2 . E k s p o r : %

3 . M e r k P r o d u k ( m i l i k s e n d i r i / l i s e n s i ) :

X I . Gudang untuk penyimpanan bahan dan hasil produksi

N o . L o k a s i G u d a n g L u a s J e n i s b a r a n g y a n g d i s i m p a n K e t e r a n g a n

X I I . Peralatan Kemetrologian

N o . J e n i s U T T P B a n y a k n y a T a h u n P e n e r a a n

1 . U k u r a n

2 . T a k a r a n

3 . T i m b a n g a n : - T i m b a n g a n M e j a - C e n t i s i m a l B o b o t - D a e i n L o g a m

4 . P e r l e n g k a p a n - A n a k T i m b a n g a n - L a i n n y a

5 . T a n g k i p e n y i m p a n a n B B M

Xin. Sumber Daya Energi

N o . N a m a d a n S p e s i f i k a s i S a t u a n K a p a s i t a s T e r p a s a n g

J u m l a h P e m a k a i a n /

T a h u n K e t e r a n g a n

1 . A i r

a . A B T b . A P T

L i t e r / d e t i k L i t e r / d e t i k

2 . E n e r g i P e n g g e r a k a ) L i s t r i k

- P E N - M i l i k S e n d i r i

b ) G a s

c ) L a i n - l a i n

K V A K V A

m m e f / h a r i

XIV. Pengendalian Pencemaran a. S p e s i f i k a s i L i m b a h y a n g d i k e l u a r k a n

N o . J e n i s V o l u m e S a t u a n C a r a P e n a n g a n a n

L i m b a h * )

1 . P a d a t

2 . C a i r

3 . G a s

4 . L a i n - l a i n

* ) D i i s i s e s u a i d e n g a n m e s i n / p e r a l a t a n p e n g e n d a l i a n p e n c e m a r a n y a n g d i g u n a k a n

b . P e n g e l o l a a n d a n P e m a n t a u a n L i n g k u n g a n H i d u p D i i s i s e s u a i d e n g a n R K L d a n R P L d a r i A M D A L , U K L U P L a t a u S P P L

* ) - R K L - R P L - A M D A L - U K L

- U P L - S P P L

R e n c a n a P e n g e l o l a a n L i n g k u n g a n R e n c a n a P e m a n t a u a n L i n g k u n g a n A n a l i s a M e n g e n a i D a m p a k L i n g k u n g a n U p a y a P e n g e l o l a a n L i n g k u n g a n d a n U p a y a P e m a n t a u a n L i n g k u n g a n S u r a t P e r n v a t a a n P e n g e n d a l i a n L i n g k u n g a n

2 ) C o r e t y a n g t i d a k p e r l u

D e m i k i a n s u r a t p e r m o h o n a n i n i t e l a h d i i s i / d i b u a t d e n g a n s e b e n a m y a d a n a p a b i l a d i k e m u d i a n

h a r i t e r n y a t a k e t e r a n g a n d a n a t a u d a t a y a n g t e l a h d i s a m p a i k a n t e r s e b u t t i d a k b e n a r , k a m i b e r s e d i a

d i c a b u t S l U I - n y a d a n b e r s e d i a d i t u n t u t s e s u a i d e n g a n p e r a t u r a n p e r u n d a n g - u n d a n g a n y a n g b e r l a k u .

B o y o l a l i ,

P e m i l i k / d i r e k t u r / p e n a n g g u n g j a w a b p e r u s a h a a n 2 )

4)

C a t a t a n :

1 . L e m b a r P e r t a m a : K e p a l a D i n a s

2 . L e m b a r K e d u a : A r s i p P e r u s a h a a n y a n g b e r s a n g k u t a n

2 ) C o r e t y a n g t i d a k p e r l u 4 ) T a n d a t a n g a n p e m i l i k / d i r e k t u r / p e n a n g g u n g j a w a b p e r u s a h a a n d a n m e t e r a i R p . 6 . 0 0 0 , -

( e n a m r i b u r u p i a h )