PT.

WASKITA SRIWIJAYA TOL

FINAL REPORT
SOIL MATERIAL TESTING

Soure : Borrow Material Quarry Indralaya (01)

PT. Sumber Diri Sembilan

KAYU AGUNG - PALEMBANG - BETUNG TOLL ROAD PROJECT

SECTION 2A STA. 39+875 - STA. 41+520

CONSULTANT PROJECT : MAIN CONTRACTOR :

PT. PERENTJANA DJAJA PT. WASKITA KARYA (PERSERO), Tbk

 KAYU AGUNG - PALEMBANG - BETUNG TOLL ROAD PROJECT
SECTION 2A STA. 39+875 - STA. 41+520

RE-SETTING OF SPEEDY MOISTURE CONTENT GAUGE

COMPARISON WITH OVEN DRYING

Date of test Sample no.

Location Date of sampling
Material Tested by

Test By,
Speedy Moisture Content Gauge Oven Dry
No
Dial reading (%) Factor correction = dial x 2 Moisture Content (%)

Mengetahui, Diperiksa dan disetujui, Dibuat Oleh,

Owner Consultant Contractor
PT. Waskita Sriwijaya Tol PT. Perentjana Djaja PT. Waskita Karya (Persero), Tbk
 KAYU AGUNG - PALEMBANG - BETUNG TOLL ROAD PROJECT
SECTION 2A STA. 39+875 - STA. 41+520

SIEVE ANALYSIS FOR AGGREGATE

AASHTO T88-97 _ ASTM C33
Date of test Sample no.
Location Date of sampl
Material Tested by

Weight sample I : 6499.0 gram Weight sample II6046 gram

Cumulative Percent Cumulative Percent Average

Sieve Size
Wt.Sample % Retained Passing Wt.Sample % Retained Passing Percent Spec. Limit
ASTM mm (gr) (gr) (%) (gr) (gr) (%) Passing
#4 0.00 100.00 5735.0 94.86 5.14 52.57 0 - 15
# 10
# 20 0.00
# 30 0.00
# 40 0.00
# 60 0.00 100.00 6046.0 100.00 0.00 50.00
# 80
# 100
# 200
PAN

Percentage passing
0.010 0.100 1.000 10.000 100.000
12.70 25.40 50.80
100.00

80.00

60.00

` 40.00

20.00

0.149 0.279 Sieve 1.190

0.590 Size ( 2.380
mm ) 4.760 9.530 19.05 38.10 63.50 0.00
0.074

DISETUJUI OLEH DIPERIKSA OLEH DIAJUKAN OLEH

OWNER KONSULTAN KONTRAKTOR
PT. Waskita Sriwijaya Tol PT. Perentjana Djaja PT. Waskita Karya (Persero), Tbk
Tgl Tanda tangan Tgl Tanda tangan Tgl Tanda tangan

Nama Nama Nama

 KAYU AGUNG - PALEMBANG - BETUNG TOLL ROAD PROJECT
SECTION 2A STA. 39+875 - STA. 41+520

SUMMARY TEST OF SOIL

Date of test : 28 November 2016 Sample No. : 011/KPLB/S3/11/2016

Location : Borrow Material Quarry Indralaya (01) Date of Sampling : 24-Nov-16

Material : Lempung , Coklatmuda Tested by : Team Lab
Depth of Semple : ±50cm

SUMMARY OF TEST

TEST REPORT
TEST DESCRIPTION CODE / STANDARD
SPEFIKASI RESULT
Max. Dry Density ( MDD ) = 1.516 Gr / cm3
1. Laboratory Compaction AASHTO T99 / T180 Opt.Moisture Cont.( OMC ) = 25.23 %

2. Specific Gravity AASHTO T100-82 2.636

Sand = 8.51 %
3. Particle Size Analysis ASTM D 422 Silt = 43.56 %
Clay = 47.93 %
LL = 40.27 %
4. Atterberg Limits AASHTO T89-96 PL = 24.29 %
PI = 15.98 %

5. Soil Clasiffication based on ASTM D 2487 CL Lean Clay

Min CBR 100% : 6 % C.B.R 100 % " = 6.14 % ( Soaked )

Activity : < 1.25 C.B.R 95 % = 4.19 % ( Soaked )
6. California Bearing Ratio ( CBR ) AASHTO T- 193
Swelling : < 1.25 Activity = 0.333 %
Fctor Swelling = 1.02 %

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Mengetahui, Konsultan Supervisi Kontraktor
Owner PT. Perentjana Djaja PT. Waskita Karya (Persero), Tbk
PT. Waskita Sriwijaya Tol

Name : Name : Name :

Date : Date : Date :
 GRAINSIZE DISTRIBUTION CURVE

LOCATION DATE : 28 November 2016

SAMPLE FROM
PE RCEN T FIN E R B Y W E IGH T : Borrow Material Quarry Indralaya (01)

CLAY SILT SAND GRAVEL

100

90

80

70

60

50

40

30

20

10

0
0.001 0.01 0.1 1 10
GRAINSIZE IN MILIMETER

Sand Fraction Silt Fraction Clay Fraction Cu d 60

d 20
d 10

8.51 43.56 47.93

 JALAN TOL KAYU AGUNG - PALEMBANG - BETUNG
SECTION 2A STA 39+875 - STA 41+520

GRAIN SIZE ANALYSIS (Finer Part)

Location : Borrow Material Quarry Indralaya (01) Sp.Gravity (Gs) : 2.636
Sampling date : 24 Nov 2016 Plasticity Index : 15.98 %
Testing date : 28 November 2016 Deflocculatiing agent :
Tested by : Team LAB Finer then 2.0 mm (P20) : 100 %
Weight of sample ( Ws ) 55
I. Water content of air dry soil sample
Sample no. I II Average ( W ' )
Weight of wet soil + container gr 59.00 52.00 Wt of oven dry sample :
Weight of dry soil + container gr 49.00 43.00
Weight of container gr 10.60 10.35 Wd = (100 x Ws)
Weight of water gr 10.00 9.00 100 + W '

Weight of dry soil gr 38.40 32.65 Wd = 43.37

Water content W (%) 26.04 27.57 26.80

II. Hydrometer Analysis Graduated cyl. No. : Hydrometer No. :

1 2 3 4 5 6 7 8 9 10 11 12
Elapsed Hydrometer Reading Temp. Cum.finer Corrected %
time (T) Dec.Part r'= o
C L L/T L/T 30 h d a P finer part
Min r r + Cm 980 (Gs-Gw) mm (r'.a/Wd).100 P x P20
1 39 40.00 28 10.7 10.700 3.271 0.0120 0.0393 0.99 91.30 91.30

2 36 37.00 28 11.1 5.550 2.356 0.0120 0.0283 0.99 84.45 84.45

5 34 35.00 28 11.7 2.340 1.530 0.0120 0.0184 0.99 79.89 79.89
15 31 32.00 28 12.2 0.813 0.902 0.0120 0.01082 0.99 73.04 73.04
30 28 29.00 28 12.5 0.417 0.645 0.0120 0.00775 0.99 66.19 66.19
60 24 25.00 28 13 0.217 0.465 0.0120 0.00559 0.99 57.06 57.06
240 20 21.00 28 14 0.058 0.242 0.0120 0.0029 0.99 47.93 47.93
1440 15 16.00 28 14.5 0.010 0.100 0.0120 0.0012 0.99 36.52 36.52

Cm = Miniscuss Correction 1 Gw = Specific Gravity of water at ToC h = Viscosity coef. Of water

III. SIEVE ANALYSIS
sieve Cumulative Weight Cumulative cumulative cumulative Correction
opening soil retained cont. weight percent reetained percent finer percent finer part
mm + container (gr) gr Soil Ret. (gr) % P' P' x P20
0.850 0 0.00 100.00 100.00
0.420 0.15 0.35 99.65 99.65
0.250 0.65 1.50 98.50 98.50
0.105 1.25 2.88 97.12 97.12
0.074 3.69 8.51 91.49 91.49

REMARKS :

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Mengetahui, Konsultan Supervisi Kontraktor
Owner PT. Perentjana Djaja PT. Waskita Karya (Persero), Tbk
PT. Waskita Sriwijaya Tol

Name : Name : Name :

Date : Date : Date :
 JALAN TOL KAYU AGUNG - PALEMBANG - BETUNG
SECTION 2A STA. 39+875 - STA. 41+520

SPECIFIC GRAVITY OF SOIL TEST

Material : Lempung , Coklatmuda Date of Sampling : 24 Nov 2016
Sample from : Borrow Material Quarry Indralaya (01) Date of Testing : 28 Nov 2016

TEST NUMBER I II AVERAGE

1 Pycnometer number II III
2 Weight of picnometer + soil Ws 54.00 54.00
3 Weight of picnometer Wp 34.00 33.00
4 Weight of sample W=Ws-Wp 20.00 21.00
5 Weight of picnometer + sample + water Wo 149.50 151.00
6 Weight of picnometer + water at 20 o C Ww 137.00 138.0
7 Temperature at Tx 28.00 28.0
8 Density water at Tx k 0.9963 0.9963
(Ww+W-Wo)
9 Volume V= 7.528 8.030
K

10 Specific Gravity of soil W/V 2.657 2.615 2.636

Table 1 : Relative Density of water and conversion Factor K

for Various Temperature
Temp. o
C Relative Density Conversion Faktor K
18 0.998624 1.0004
19 0.998435 1.0002
20 0.998234 1.0000
21 0.998023 0.9998
22 0.997802 0.9996
23 0.997570 0.9993
24 0.997329 0.9991
25 0.997077 0.9989
26 0.996816 0.9986
27 0.996545 0.9983
28 0.996265 0.9980
29 0.995976 0.9977
30 0.995678 0.9974

Diperiksa dan Disetujui Oleh, Dibuat Oleh,

Mengetahui, Konsultan Supervisi Kontraktor
Owner PT. Perentjana Djaja PT. Waskita Karya
PT. Waskita Sriwijaya Tol

Name : Name : Name :

Date : Date : Date :
 KAYU AGUNG - PALEMBANG - BETUNG TOLL ROAD PROJECT
SECTION 2A STA. 39+875 - STA. 41+520

Material : Lempung , Coklatmuda

Source of Material : Borrow Material Quarry Indralaya (01)
Date of Sampling : 24 November 2016
Compactor : 26 November 2016
Soaking : 26 November 2016

Compaction Data C B R Data

Water Content Dry Density Blow CBR gd

No.
ω (%) gd (gr/cm3) ( time ) (%) ( gr/cm3 )
1 22.59 1.401 10 x 2.86 1.383
2 23.69 1.447 25 x 5.07 1.479
3 25.23 1.516 65 x 7.61 1.571
4 27.29 1.415
5 29.45 1.333

Relationship Chart of Compaction and CBR Test Result

CB R
Standard Proctor
1.600 1.600
yd (gr/cm3)

1.550 1.550
C BR 100% = 6.14 %
MDD = 1,516 gr/cc
1.500 1.500

CBR 95% = 4,19 %

1.450 1.450

1.400 1.400

OMC = 25,23%
1.350 1.350

1.300 1.300
19 21 23 25 27 29 0 2 4 6 8 10 12
Water Content (%) CBR (%)

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Mengetahui, PT. Perentjana Djaja
Owner PT. Waskita Karya
PT. Waskita Sriwijaya Tol

Name : Name : Name :

Date : Date : Date :
 JALAN TOL KAYU AGUNG - PALEMBANG - BETUNG
SECTION 2A STA. 39+875 - STA. 41+520

CBR LABORATORY
( AASHTO T- 193 )
Date of test 26-Nov-16 Sample no. 011/KPLB/S3/11/2016
Location Borrow Material Quarry Indr Date of sampli 24-Nov-16
Material Lanau, coklatmuda Tested by Team Lab

EXPANS OF SAMPLE DENSITY DETERMINATION Before After

Date ### 27-Nov-16 ### 29-Nov-16 a Weight. of Sample+Mold (gr) 10373.0 10685.0
Time 17.00 17.00 17.00 17.00 b Weight of Mold (gr) 6725.0 6725.0
Reading 1.778 1.789 1.790 1.798 c Volume of Mold (cm3) 2119.9 2119.9
Height sample (mm) 121.4 d Weight of Wet Soil (gr) 3648.0 3960.0
Swelling (%) 1.48 e Wet Density (gr/cm3) 1.721 1.868
f Dry Density (gr/cm3) 1.325 1.383
CBR. DETERMINATION Blows 10
Time Penetration Dial Reading Loading ( lb )
140
(Min) ( in ) Up. Bottom Up. Bottom
1/4 0.0125 1.2 11.71
130
1/2 0.0250 2.3 22.44
1 0.0500 4.8 46.84 120
1 1/2 0.0750 7.0 68.31
2 0.1000 8.8 85.87 110
3 0.1500 10.4 101.48
4 0.2000 12.0 117.10 100

6 0.3000 13.0 126.85

Load (lb)

90
8 0.4000 13.5 131.73
10 0.5000 14.0 136.61
80
Calibration of Ring 9.758
WATER CONTENT Before After 70
a Weight of Wet Soil + Tare (gr) 405.00 365.00
60
b Weight of Dry Soil + Tare (gr) 324.00 284.00
c Weight of Tare (gr) 53.00 53.00
50
d Weight of Water (gr) 81.00 81.00
e Weight of Dry Soil (gr) 271.00 231.00 40
f Water Content (%) 29.89 35.06
30
CBR . VALUE
20
0.1" 0.2"
85.87 x 100% 117.10 x 100%
10
Up 3 x 1000 3 x 1500
2.86 % 2.60 % 0
x 100% x 100% 0 0.1 0.2 0.3 (in) 0.4
Penetration 0.5
Bottom 3 x 1000 3 x 1500
0.00 % 0.00 % Chart of CBR Test

Mengetahui, Diperiksa dan Disetujui Oleh, Dibuat Oleh,

Owner Konsultan Supervisi Kontraktor
PT. Waskita Sriwijaya Tol PT. Perentjana Djaja PT. Waskita Karya

Name : Name : Name :

Date : Date : Date :
 JALAN TOL KAYU AGUNG - PALEMBANG - BETUNG
SECTION 2A STA. 39+875 - STA. 41+520

CBR LABORATORY
( AASHTO T- 193 )
Date of test 26-Nov-16 Sample no. 011/KPLB/S3/11/2016
Location Borrow Material Quarry Indr Date of sampli 24-Nov-16
Material Lanau, coklatmuda Tested by Team Lab

EXPANS OF SAMPLE DENSITY DETERMINATION Before After

Date ### 27-Nov-16 ### 29-Nov-16 a Weight. of Sample+Mold (gr) 10673.0 10928.0
Time 17.00 17.00 17.00 17.00 b Weight of Mold (gr) 6865.0 6865.0
Reading 1.311 1.380 1.410 1.435 c Volume of Mold (cm3) 2119.9 2119.9
Height sample (mm) 120.1 d Weight of Wet Soil (gr) 3808.0 4063.0
Swelling (%) 1.19 e Wet Density (gr/cm3) 1.796 1.917
f Dry Density (gr/cm3) 1.413 1.479
CBR. DETERMINATION Blows 35
Time Penetration Dial Reading Loading ( lb )
(Min) ( in ) Up. Bottom Up. Bottom 240
1/4 0.0125 1.8 17.56 230
1/2 0.0250 4.8 46.84 220
1 0.0500 9.8 95.63 210
1 1/2 0.0750 13.1 127.83 200
2 0.1000 15.6 152.22 190
3 0.1500 18.4 179.55 180
4 0.2000 20.8 202.96 170
6 0.3000 23.2 226.38 160
Load (lb)

8 0.4000 24.2 236.14 150

10 0.5000 24.4 238.09 140
Calibration of Ring 9.758 130
WATER CONTENT Before After 120
a Weight of Wet Soil + Tare (gr) 415.00 400.00 110
b Weight of Dry Soil + Tare (gr) 338.00 321.00 100
c Weight of Tare (gr) 54.00 54.00 90
d Weight of Water (gr) 77.00 79.00 80
e Weight of Dry Soil (gr) 284.00 267.00 70
f Water Content (%) 27.11 29.59
60
50
CBR . VALUE 40
0.1" 0.2" 30
152.22 x 100% 202.96 x 100% 20
Up 3 x 1000 3 x 1500
10
5.07 % 4.51 %
0
x 100% x 100% 0 0.1 Penetration
0.2 0.3 (in) 0.4 0.5
Bottom 3 x 1000 3 x 1500
0.00 % 0.00 % Chart of CBR Test
Diperiksa dan Disetujui Oleh, Dibuat Oleh,
Konsultan Supervisi Kontraktor
Mengetahui, PT. Perentjana Djaja PT. Waskita Karya
Owner
PT. Waskita Sriwijaya Tol

Name : Name : Name :

Date : Date : Date :
 JALAN TOL KAYU AGUNG - PALEMBANG - BETUNG
SECTION 2A STA. 39+875 - STA. 41+520

CBR LABORATORY
( AASHTO T- 193 )
Date of test 26-Nov-16 Sample no. 011/KPLB/S3/11/2016
Location Borrow Material Quarry Indr Date of sampli 24-Nov-16
Material Lanau, coklatmuda Tested by Team Lab

EXPANS OF SAMPLE DENSITY DETERMINATION Before After

Date ### 27-Nov-16 ### 29-Nov-16 a Weight. of Sample+Mold (gr) 11010.0 11095.0
Time 17.00 17.00 17.00 17.00 b Weight of Mold (gr) 6865.0 6865.0
Reading 1.200 1.206 1.211 1.220 c Volume of Mold (cm ) 3
2119.9 2119.9
Height sample (mm) 120.1 d Weight of Wet Soil (gr) 4145.0 4230.0
Swelling (%) 1.02 e Wet Density (gr/cm ) 3
1.955 1.995
f Dry Density (gr/cm3) 1.559 1.571
CBR. DETERMINATION Blows 65
Time Penetration Dial Reading Loading ( lb )
(Min) ( in ) Up. Bottom Up. Bottom

0
00 00 00 00 00 . 00 . 00 . 00 . 00 . 00 . 00 . 00 . 00 . 00 . 00 . 00 . 00 . 00
1/4 0.0125 1.8 17.56
0 20 40 60 80 00 20 40
1/2 0.0250 5.8 56.60
0
3

1 0.0500 12.0 117.10

0
3

1 1/2 0.0750 18.1 176.62

0

2 0.1000 23.4 228.34

3

3 0.1500 28.0 273.22

0
2

4 0.2000 31.0 302.50

0

6 0.3000 33.5 326.89

2
Load (lb)

8 0.4000 34.6 337.62

0
2

10 0.5000 35.2 343.48

0
2

Calibration of Ring 9.758

20

WATER CONTENT Before After

0
0

a Weight of Wet Soil + Tare (gr) 398.00 420.00

18

b Weight of Dry Soil + Tare (gr) 328.00 342.00

0
16

c Weight of Tare (gr) 53.00 53.00

0

d Weight of Water (gr) 70.00 78.00

14

e Weight of Dry Soil (gr) 275.00 289.00

0
12

f Water Content (%) 25.45 26.99

0
10

0
0. 20. 40. 60. 80.

CBR . VALUE
0

0.1" 0.2"
0

228.34 x 100% 302.50 x 100%

Up 3 x 1000 3 x 1500
0

7.61 % 6.72 %
0

x 100% x 100% 0 0.1 0.2 0.3

Penetration (in) 0.4 0.5
Bottom 3 x 1000 3 x 1500
0.00 % 0.00 % Chart of CBR Test

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Mengetahui, Konsultan Supervisi Kontraktor
Owner PT. Perentjana Djaja PT. Waskita Karya
PT. Waskita Sriwijaya Tol

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Date : Date : Date :
 PROYEK JALAN TOL KAYU AGUNG - PALEMBANG - BETUNG
SECTION 2A STA. 39+875 - STA. 41+520

LIQUID AND PLASTIC LIMIT TEST

AASHTO T89-96
Date of test November 28, 2016 Sample no. 011/KPLB/S3/11/2016

Location Borrow Material Quarry IndraDate of sampling 24-Nov-16

Material Lanau, coklatmuda Tested by Team Lab

LIQUID LIMIT PLASTIC LIMIT

TEST No. 1 2 3 4 1 2

Liquid Limit Plastic Limit

Number of Blows 40 32 22 15
Tare No. 1 2 3 4 A C
Weight of Wet Soil + Tare ( A gr 16.60 15.10 17.10 22.00 17.00 18.00
Weight of Dry Soil + Tare ( B gr 15.30 14.05 15.30 18.20 15.90 16.55
Weight of Tare (C gr 11.00 11.00 11.00 11.00 11.00 11.00
Weight of Water D =(A-B) gr 1.30 1.05 1.80 3.80 1.10 1.45
Weight of Dry Soil E=(B-C) gr 4.30 3.05 4.30 7.20 4.90 5.55
Water Content F=(D/E*100) % 30.23 34.43 41.86 52.78 22.45 26.13
M o u s t u re C o u n t e n t %

Average 30.23 34.43 41.86 52.78 24.29

LIQUID LIMITS ( % )
40.27

65
60
55
52.7777777778 PLASTIC LIMITS ( % )
50
45
24.29
40 41.8604651163
35 34.4262295082
30 30.2325581395
25
20 PLASTIC INDEX ( % )
15 15.98
10 25.0
10 Number of Blows N 100

SOIL CLASSIFICATION U.S.C SUB GROUP AASHTO

P LA ST IC INDEX

LIQUID LIMIT

160
A-5

120 140
A-7-5
100 120
A-7
100 A-7-
80
6
80
60
OH-MH 60
40
40
A-4

20 A-6
20
0
0
0 15 30 45 60 75 LIMIT
LIQUID 90 105 120 135 150 0 20 40
PLASTIC60
INDEX 80 100

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Mengetahui, Konsultan Supervisi Kontraktor
Owner PT. Perentjana Djaja PT. Waskita Karya
PT. Waskita Sriwijaya Tol

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Date : Date : Date :
 PROYEK JALAN TOL KAYU AGUNG - PALEMBANG - BETUNG
SECTION 2A STA. 39+875 - STA. 41+520

COMPACTION TEST
AASHTO T99 / T180

Date of test ### Sample No. 011/KPLB/S3/11/2016

Location Borrow Material Quarry Indralaya Date of sampling November 24, 2016
Material Lanau, coklatmuda Tested by Team Lab
Test No. 1 2 3 4 5

Weight of Wet Soil (gr) 3000 3000 3000 3000 3000

Water Added (cc) 240 300 360 420 480
Water Added (%) 8 10 12 14 16
DENSITY DETERMINATION

a Weight. of Sample+Mold (gr) 4958.0 5025.0 5125.0 5035.0 4965.0

b Weight of Mold (gr) 3375.0 3375.0 3375.0 3375.0 3375.0
c Volume of Mold (cm3) 921.6 921.6 921.6 921.6 921.6
d Weight of Wet Soil ( a-b ) (gr) 1583.0 1650.0 1750.0 1660.0 1590.0
e Wet Density (d/c) (gr/cm3) 1.718 1.790 1.899 1.801 1.725
f Water content (%) 22.59 23.69 25.23 27.29 29.45
g Dry Density (100*e/f+100)(gr/cm3) 1.401 1.447 1.516 1.415 1.333
h Zero Air Void 1.652 1.623 1.583 1.533 1.484
WATER CONTENT
Tare number E E 64 13
a Weight of Wet Soil + Tare (gr) 68.00 68.00 71.00 72.00 74.50
b Weight of Dry Soil + Tare (gr) 57.60 57.20 59.05 59.05 60.25
c Weight of Tare (gr) 11.57 11.62 11.68 11.60 11.87
d Weight of Water ( a-b ) (gr) 10.4 10.8 12.0 13.0 14.3
e Weight of Dry Soil ( b- c) (gr) 46.0 45.6 47.4 47.5 48.4
f Water Content ( 100*d/e) (%) 22.6 23.7 25.2 27.3 29.5
Average Water Content (%) 22.59 23.69 25.23 27.29 29.45

COMPACTION CURVE RESULT OF TEST

Dry Density (t/m3)

Compaction Methode Standard

Specific Gravity (gr/cm 3) 2.636
1.900
Wet density Max. (gr/cm 3) 1.859
Water Content Optimum (%) 25.23
1.800 Dry density Max. (gr/cm 3) 1.516
95 % Dry density Max. (gr/cm3) 1.441
1.700

1.600 Rammer :
MDD = 1,516 gr/cc
Weight : 2500 gr.
1.500 Height of drop : 304,8mm
Blows per layer : 25
Number of layer : 3
1.400
OMC = 25,23%
1.300

1.200
22.0 23.0 24.0 25.0
Water26.0 27.0
Content (%) 28.0 29.0 30.0 31.0

Diperiksa dan Disetujui Oleh, Dibuat Oleh,

Mengetahui, Konsultan Supervisi Kontraktor
Owner PT. Perentjana Djaja PT. Waskita Karya
PT. Waskita Sriwijaya Tol

Name : Name : Name :

Date : Date : Date :