one-door integrated office special capital city … file27.07.2016 · to standardize the output...

ONE-DOOR INTEGRATED OFFICE

SPECIAL CAPITAL CITY PROVINCE OF JAKARTA

February 23, 2016

To

Dear. 1. Heads of City PTSP Office

/Administrative City

2. Heads of Implementing Unit

Department of Sub-District Level

PTSP

3. Heads of Implementing Unit

Department of Village Level

PTSP

In

Jakarta

CIRCULATION LETTER

NUMBER 14/SE/2016

CONCERNING

FORM OFSERVICE OUTPUT OF STATEMENT OF COMMITMENT TO IMPLEMENT

ENVIRONMENTAL MANAGEMENT AND MONTORING (SPPL) AND

ENVIRONMENTAL MANAGEMENT AND ENVIRONMENTAL MONITORING (UKL –

UPK) IN DKI JAKARTA PROVINCE

To standardize the output forms of the SPPL and UKL/UPL

Services in BPTSP Vicinity of DKI Jakarta Province, we hereby

ask you to pay attention the matters hereunder:

1. The sample of SPPL form as stated in the appendix 1 of

this circulation letter.

2. The sample of UKL/UPL from as stated in the appendix 2 of

this circulation letter.

We hereby conclude this circulation letter for your attention

and to be implemented properly and responsibly.

Head of One-Door Integrated Service Agency

Special Capital City of Jakarta Province

[Sealed and signed]

Edy Junaedi

NIP 197611301995111001

Copied to:

1. Governor of DKI Jakarta Province

2. Vice of Governor of DKI Jakarta Province

3. Regional Secretary of DKI Jakarta Province

4. Assistants of Regional Secretary of DKI Jakarta Province

5. Inspector of Province Region of DKI Jakarta Province

6. Mayors / Administrative Regent of DKI Jakarta Province

7. Heads of Sub-District

8. Heads of Village

Appendix 1 : Circulation Letter of

Head of BPTSP of DKI

Jakarta Province

Number 14/SE/2016

Dated February 23, 2016

SAMPLE OF OUTPUT FORM OF SPPL

STATEMENT OF COMMITMENT TO IMPLEMENT ENVIRONMENTAL MANAGEMENT

AND MONTORING (SPPL)

We, the undersigned:

1. Name :

2. Position :

3. Address :

4. Telephone Number :

As the person in charge of environmental management of:

1. Company/Business Name :

2. Company/Business Address :

3. Company Telephone Number :

4. Type of Business/Nature of Business :

5. Production Capacity :

The environmental impacts resulted are in the forms of:

1.

2.

3.

4.

5. and so forth

Makes the plan to manage and monitor the environmental effects

through:

1.

2.

3.

4.

5. and so forth.

Basically has the commitment to make every effort to implement

all environmental impact management and monitoring aforementioned,

and is willing to be supervised by the competent authority.

Date, Month, Year

Person Stated,

Duty Stamped and signature

(……………………………….)

Head of One-Door Integrated Service Agency

Special Capital City of Jakarta Province

[Sealed and signed]

Edy Junaedi

NIP 197611301995111001

Appendix 2 : Circulation Letter of

Head of BPTSP of DKI

Jakarta Province

Number 14 of 2016

Dated February 23, 2016

SAMPLE OF OUTPUT FORM OF UKL/UPL

UKL UPL DOCUMENT

(in Accordance with Appendix IV of Regulation of LH Minister

No. 16 of 2012)

A. INITIATOR IDENTITY

1. Initiator Name :

2. Initiator Address :

3. Telephone Number/Mobile/Fax :

4. Institution/Company :

5. Name of Person in Charge :

6. Institution/Company Address :

7. Telephone Number/Mobile/Fax :

B. BUSINESS PLAN and/or ACTIVITY

1. Business Plan and/or Activity :

2. Location of Activity :

a. Address :

b. Village :

c. Sub-District :

d. City :

e. Province :

f. Land Border :

a) North Side :

b) East Side :

c) South Side :

d) West Side :

(Please attach the map according to the cartography

principles and/or location drawing in adequate scale )

3. Scale/Capacity of business plan and/or activity

(Please mention the area and or length and/or volume

and/or capacity or other measurement that can be used

to provide description on activity scale).

4. The Outline of Component of Business Plan and / or Activity

In this section, the initiator describes:

a. The conformity of the activity plan location with

spatial layout

(describe the conformity of business plan location

and / or activity with layout plan according to the

provisions of rules and regulation. The information

is also presented in the form of overlay map between

border site map of business and /or activity plan

project with applicable and predetermined Spatial

Plan. The evidences supporting conformity with spatial

layout shall be attached)

b. The Licensing/Non-Licensing that already had and has

not had that support the business and / or activity

can be implemented (shall be attached).

No

Types of

Licensing/Non-

Licensing Documents

Remark

I. Already had

1.

2.

3. and so forth

II. Has not had

1.

2.

3. and so forth

c. The Components of activity plan that may result in

environmental impact

(describe the components of business plan and / or

activity believed in resulting environmental impact)

No. Stage Activity Activity

Description Time

1 Pre-construction 1. 1.

2. 2. Month ……

to Month ……

3. 3. Year ……

4. and so

forth

4. and so

forth

2 Construction 1. 1.

2. 2. Month ……

to Month ……

3. 3. Year ……

4. and so

forth

4. and so

forth

3 Operation 1. 1.

2. 2. Month ……

to Month ……

3. 3. Year ……

4. and so

forth

4. and so

forth

(Note: only for big scale business and/or activity,

such as paper industry, textile etc. please attach

the process flow chart along with mass balance and

water balance)

C. ENVIRONMENTAL IMPACT RESULTED AND ENVIRONMENTAL MANAGEMENT AND MONITORING

To describe the Environmental Impacts and Environmental Management and Monitoring, it is

prepared the following matrix:

Impact Environmental Management Environmental Monitoring Agency

Monitoring

and Managing

the

Environment

REMARK

Source

Type

Measurement

Form of

Management

Location

Period

Form of

Monitoring

Location

Period

(Write down

the activities

resulted

impact on

the

environment)

(Write down

environmental

impacts that

are likely to

occur)

(Write down

measurement

that can

express the

impact

measurement)

(Write down

forms / types

of

environmental

management

planned to

manage any

impact

resulted)

(Write down

information

where the

concerned

environmental

impact is

implemented)

(write down

the

information

on time /

period when

the

environmental

management

was planned )

(write down

the

information

about way,

method,

and/or

technique to

monitor the

environment

quality that

becomes the

success

indicator of

environmental

management)

(write down

the

information

about the

location

where the

environmental

monitoring is

performed)

(write down

the

information

about

time/period of

the

environmental

monitoring

form planned)

(write down

the institution

that related to

environmental

management

and

monitoring)

(write down

other

information

that is

necessary to

communicate

to explain

matters that

are required)

Pre-

Construction

stage

1………….. 1………….. 1………….. 1………….. 1………….. 1………….. 1………….. 1………….. 1………….. 1…………..

2…………. 2…………. 2…………. 2…………. 2…………. 2…………. 2…………. 2…………. 2…………. 2………….

3………… 3………… 3………… 3………… 3………… 3………… 3………… 3………… 3………… 3…………

and so forth and so forth and so forth and so forth and so forth and so forth and so forth and so forth and so forth and so forth

Construction

stage

1………….. 1………….. 1………….. 1………….. 1………….. 1………….. 1………….. 1………….. 1………….. 1…………..

2…………. 2…………. 2…………. 2…………. 2…………. 2…………. 2…………. 2…………. 2…………. 2………….

3………… 3………… 3………… 3………… 3………… 3………… 3………… 3………… 3………… 3…………


Operation

stage

1………….. 1………….. 1………….. 1………….. 1………….. 1………….. 1………….. 1………….. 1………….. 1…………..

2…………. 2…………. 2…………. 2…………. 2…………. 2…………. 2…………. 2…………. 2…………. 2………….

3………… 3………… 3………… 3………… 3………… 3………… 3………… 3………… 3………… 3…………


(Note: this section may be supplemented by map, sketch, or drawing related to environmental management

and monitoring programs)

D. NUMBERS AND TYPES OF PERMIT FOR ENVIRONMENTAL PROTECTION

AND MANAGEMENT REQUIRED

Types of permit for environmental protection and management

required are as follows:

1. Utilization of liquid waste to water or source of water;

2. Utilization of liquid waste for application to the soil;

3. Temporary storage B3 waste;

4. Collecting B3 waste;

5. Utilization of B3 waste:

6. Processing of B3 waste;

7. Hoarding B3 waste;

8. Disposing liquid water to the sea;

9. Pumping to environmental media;

10. Liquid water disposal by injecting; and

11. Emission; and/or

12. Introducing organism of genetic engineering to environment.

(Note: selected according to the need)

E. (THE LETTER HEAD IF THE INITIATOR IS COMPANY/INSTITUTION)

STATEMENT

No.

The undersigned:

Name :

Position :

Name of Business and / or Activity

:

Address :

:

Type of Business and / or Activity

:

Hereby states that:

1. The document of UKL UPL of business and / activity

………………………………… in ………………………………… and the facility prepared

correctly;

2. We are committed to implement and comply with the provisions

and obligation as stated on the Document of UKL UPL of

business and / activity ………………………………… in …………………………………

and the facility.

3. If we do not implement the action as stated on the point

2, then we will not object to be sanctioned according to

regulation in force.

In witness whereof, this statement is prepared correctly

to be used in a proper manner.

Jakarta, 201 …

Initiator,

Signature

Duty stamp Rp. 6,000

Stamp if the Initiator is Company/Agency

(Printed Name)

Position

F. BIBLIOGRAPHY

In this section, the sources of reference and information

used to prepare UKL UPL whether in the forms of books, magazines,

papers, article and reports of research result. The bibliography

shall be stated using the standard to write down the bibliography.

1.

2.

3.

4.

5. and so forth

G. APPENDIX

Other data and information that are relevant to the UKL

UPL form can be attached, such as:

1. Formal evidence stating that type of the activity business

is principally can be implemented;

2. Formal evidence that the plan of business location and

or activity has been in accordance with applicable spatial

plan (spatial plan conformity is shown by the presence of

the letter from Coordinating Board for National Spatial

Planning (BKPTRN) or other agencies which are in charge

of spatial planning field;

3. Other detailed information about activity plan;

4. Maps that are in accordance with cartography principles

and / or location illustration with adequate scale to

describe the locations of environmental management and

monitoring;

5. Other data and information deemed necessary.

HEAD OF ONE-DOOR INTEGRATED SERVICE AGENCY

SPECIAL CAPITAL CITY OF JAKARTA PROVINCE

[Sealed and signed]

EDY JUNAEDI

NIP 197611301995111001