PEMERINTAH KOTA PALOPO

RUMAH SAKIT UMUM DAERAH SAWERIGADING PALOPO

Jln. DR. Ratulangi Km. 7 Rampoang Kode Pos : 91914
Telepon : (0471) 331213 Faks : (0471) 3312144
Email : rsu.swg@gmail.com Website : rsudswgpalopokota.go.id

BERITA ACARA PENERIMAAN BARANG

Nomor : 882 /ALKES/BA-PB/RSU.SWG/XII/2022

Pada hari ini, Jumat Tanggal Sembilan Bulan Desember Tahun Dua Ribu Dua Puluh Dua, yang
bertanda tangan di bawah ini :

Nama : Aulia Mulgah, S.farm.,Apt

NIP : 19870920 201903 2 015
Jabatan : Pengurus Barang Farmasi

Telah menerima barang yang diserahkan sesuai Surat Pesanan/Kontrak Nomor :

729/PPK-SP/RSUD.SWG/PLP/BLUD/XI/2022 Tanggal : 02 November 2022 dan Berita Acara
Pemeriksaan dan Serah Terima Barang/Pekerjaan Nomor : 577/ALKES/BA-STB.P/RSUD.SWG/XII/2022
Tanggal : 08 Desember 2022 dengan rincian sebagai berikut :

Harga Satuan Total Harga

No. Jenis/Type/Merk/Barang/Pekerjaan Kuantitas Satuan Ket.
(Rp.) (Rp.)
1. Video Endoscopy System, 24 inch
1 unit 126.109.980 126.109.980
High Resolution LCD Monitor
MEDITECH LITHOSPLIT 4.1 DIGITAL
Intra Corporeal Pneumatic
2 1 unit 1.265.500 1.265.500
Lithotripsy System, Probes, 1.0mm
(For Ureter) PB0303
MEDITECH LITHOSPLIT 4.1 DIGITAL
Intra Corporeal Pneumatic
3 1 unit 1.265.500 1.265.500
Lithotripsy System, Probes, 1.5mm
(For Bladder) PB0304
Laparoscopy Gynecology
Instrument; Monopolar cable for
4 elctrodes and loops; dia 4mm; 1 unit 2.850.000 2.850.000
3,0m; to MARTIN/AESCULAP
equipment 582-533-04
Laparoscopy Urology Instrument,
Loop Electrode; angled; 24 / 26Fr;
5 yellow/blue; for 30 derajat 3 unit 2.850.000 8.550.000
telescopes; Bipolar system 630-240-
00B
Laparoscopy Urology Instrument,
6 Nephroscope 15 derajat 1 unit 195.000,000 195.000.000
TONO/601-122-45
Laparoscopy Urology Instrument,
7 1 Unit 4.050.000 4.050.000
Obturator 26Fr 630-420-27
Laparoscopy Urology Instrument,
8 Obturator for resectoscopy 24/26 1 unit 6.300.000 6.300.000
Fr; yellow 630-215-24
Laparoscopy Urology Instrument,
9 Obturator for Urethrotome; 21 Fr 1 unit 6.300.000 6.300.000
630-400-50
Laparoscopy Urology Instrument,
Operating Sheath, 26
Fr.nephroscopy sheath without
10 1 unit 22.500.000 22.500.000
obturator 1 turnable stopcock;
distal drainage 26 Fr; 175mm 630-
420-26
 Laparoscopy Urology Instrument,
11 RESECTOSCOPY (TUR), Working 1 unit 57.000.000 57.000.000
Element; Bipolar 630-235-60B
Laparoscopy Urology Instrument,
resectoscopy sheath; continuous
12 flow; 26Fr.;2 stopcocks;turnable 1 unit 23.450.175 23.450.175
tube without obturator; allround
perforation 630-210-26
Laparoscopy Urology Instrument,
13 Sealing Cap For Instrument Channel 1 unit 1.650.000 1.650.000
499-199-00
Laparoscopy Urology Instrument,
sheath connection with cone for
14 Ellik Evacuator; conus 32,7mm 1 unit 1.500.000 1.500.000
length tube length 115mm 582-
400-15
Laparoscopy Urology Instrument,
Stone grasping forceps; fenestrated
15 jaws for percutaneous 1 unit 19.500.000 19.500.000
nephroscope; dia 3,5mm; 350mm
630-451-35
Laparoscopy Urology Instrument,
Ball Electrode; (diameter) 3mm;
16 3 unit 2.850.000 8.550.000
24 / 26Fr.; yellow/blue; bipolar
system 630-240-15B
Laparoscopy Urology Instrument,
17 Stricture knife straight; 21Fr 630- 2 unit 3.000.000 6.000.000
405-05
Laparoscopy Urology Instrument,
18 Stricture Knife, Round Shaped; 21Fr 2 unit 3.000.000 6.000.000
630-405-15
Laparoscopy Urology Instrument,
Supplementary sheath for
19 1 unit 12.150.000 12.150.000
urethrotome lateral open; 21Fr. for
630-400-21 630-400-30
Laparoscopy Urology Instrument,
Loop electrode angled; 24 / 26Fr.
20 3 unit 2.700.000 8.100.000
yellow;for 30 (derajat) telescopes;
monopolar 630-240-00
Laparoscopy Urology Instrument,
TONTARRA Endo-Urology,
21 2 unit 10.200.000 20.400.000
NEPHROSCOPY (PCNL), Grasping
Forcep 3 Jaws 630-470-35
Laparoscopy Urology Instrument,
Knife Electrode; 24/26 Fr;
22 3 unit 2.850.000 8.550.000
yellow/blue; Bipolar system 630-
240-40B
Laparoscopy Urology Instrument,
23 Instrument Bridge for Nephroscope 1 unit 6.300.000 6.300.000
601-120-12
Laparoscopy Urology Instrument,
flexible grasper with handle, double
24 action, 4 Fr., length 600mm for 1 Unit 11.387.250 11.387.250
grasping of larger stones and
fragments S990-021-24
Laparoscopy Urology Instrument,
Urethrotome sheath visual 21Fr.; 2
25 1 unit 25.500.000 25.500.000
fixed stopcocks; graduated; guide
wire port 5Fr. 630-400-21
Laparoscopy Urology Instrument,
26 1 unit 4.500.000 4.500.000
Dilatation sleeve 30 Fr 630-430-30
Laparoscopy Urology Instrument,
27 1 unit 4.500.000 4.500.000
Dilatation sleeve 27 Fr. 630-430-27
 Laparoscopy Urology Instrument,
Dilatation set content 1x guide wire
28 rigid + 1xflexible 1x dilatation 1 unit 31.500.000 31.500.000
sleeve (diameter)
9,12,15,18,21,24FR 630-430-00
Laparoscopy Urology Instrument,
Working Element Passive Cutting;
29 Closed Handle for 4,0mm 1 unit 55.500.000 55.500.000
telescope; HF-connection down
630-235-60
Endoscopic Camera System SV-
30 1 unit 572.037.390 572.037.390
M2K30
31 Light Source SL-ED10 1 unit 175.697.100 175.697.100
Laparoscopy Urology Instrument,
Uretero-renoscope 6.0-7.5 - 9-10.2
Fr. (round 3.4mm diameter);
32 1 unit 210.000.000 210.000.000
0(derajat); 425 mm working length;
working channel 5.1 Fr., Kode
TONO/601-110-20-M
33 Generator Pulsar MB350 1 unit 256.000.000 256.000.000
Total : 1.899.962.895
Ongkos kirim : 7.500.000
Jumlah Total : 1.907.462.895
Terbilang : Satu Milyar Sembilan Ratus Tujuh Juta Empat Ratus Enam Puluh Dua Ribu Delapan Ratus
Sembilan Puluh Lima Rupiah
Catatan : Jumlah harga sudah termasuk biaya overhead dan pajak sesuai ketentuan

Demikian berita acara ini dibuat, untuk selanjutnya dipergunakan sebagaimana mestinya.

Mengetahui : Pengurus Barang

Pejabat Pembuat Komitmen RSUD Sawerigading Palopo

Irsan Anugrah, SKM.,MM Aulia Mulfah, S.Farm.,Apt

NIP : 19851110 200902 1 004 NIP : 19870920 201903 2 015