Surat Pernyataan Kapus Modopuro Barang 2019.docx

PEMERINTAH KABUPATEN MOJOKERTO DINAS KESEHATAN

UPT PUSKESMAS MODOPURO JL. S. Parman No. 10 Kec. Mojosari Mojokerto Kode Pos 61382 Jawa Timur Telp. ( 0321 ) 593130 Email : [email protected]

SURAT PERNYATAAN PENERIMAAN ALAT KESEHATAN UPT PUSKESMAS MODOPURO KABUPATEN MOJOKERTO 2018 Nomor : 028/

/416-102.15/2019

Yang bertanda tangan dibawah ini, kami: NAMA

: dr. ANGKY MEILIN WIDI SUMIJAYANTI

NIP

: 19840501 201412 2 001

JABATAN

: Kepala UPT. Puskesmas Modopuro

Menyatakan bahwa telah menerima alat kesehatan dan telah berfungsi, sebagai berikut: NO NAMA BARANG 1

Partus Set

2

Doppler

3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18

Medical Vaccine Carrier Dental Chair

Partus Set Fetal Doppler Gynekology Examination Table Infusion Stand Wheel Chair Mayo Table Medicine Cabinet Loundry Trolley Food Trolley Instrument Trolley Bedside Cabinet Children Bed Instrument Cabinet Hospital Bed 3 Crank

JUMLAH BARANG

HARGA SATUAN

HARGA TOTAL

1

23.510.000

23.510.000

1

4.500.000

4.500.000

RCW 4

1

8.943.653

8.943.653

Andini / Fortuna Premium

1

119.500.000

119.500.000

Dimeda

2

Brael / UDT 20 D

2

6.539.000

13.078.000

Sani

2

11.030.305

22.060.610

Sani

2

2.354.495

4.708.990

Sani

1

4.071.000

4.071.000

Sani

2

4.846.500

9.693.000

Sani

1

6.158.825

6.158.825

Sani

1

6.580.000

6.580.000

Sani

1

6.897.080

6.897.080

Sani

1

7.523.300

7.523.300

Sani

2

7.526.805

15.053.610

Sani

1

10.118.275

10.118.275

Sani

1

10.305.275

10.305.275

Sani

2

24.006.840

48.013.680

MERK/TYPE B BRAUN / Aesculap SHENZEN / JP200C

14.783.000

29.566.000

19

Room Devider

Sani

2

3.992.800

7.985.600 15.000.000

20

Transfussion Chair

Sani

1

15.000.000

21

Loading Strectcher

Sani

1

31.796.765

31.796.765

22

Biosafety Cabinet

Biobase/ BSC-110IIB2X

1

86.591.000

86.591.000

Leica/DM1000

1

86.999.000

86.999.000

Utas ECG / Ucard 100

1

21.512.722

21.512.722

1

5.487.000

5.487.000

1

11.851.612,5

11.851.612,5

Sani

1

52.272.200

52.272.200

Mindray / BC20S

1

108.780.000

108.780.000

23

24

25 26 27 28

Mikroskop

EKG

Nebulizer

Equitron / Sleva Series 7451 Sleva

Dry Heat Sterilizer Sani Steam Sterilizer Hematology Analyzer

Demikian Surat Pernyataan ini dibuat agar dapat dipergunakan sebagaimana mestinya.

Mojokerto, 14 Februari 2019 KEPALA UPT PUSKESMAS MODOPURO

dr. ANGKY MEILIN WIDI S. NIP. 19840501 201412 2 001