危險貨物污染危害性貨物安全適運申報單

1、危險貨物/污染危害性貨物安全適運申報單Declaration on Safety and Fitness of Dangerous GoodHazardous Goods(包裝貨物)進港 Arrival /出港 Departure (Packaged發(fā)貨人：Shipper：船名和航次：Ship s name &oyage NO.:收貨人：Con sig nee:裝卸港：Port of Loading:承運人：Carrier卸貨港：Port of Discharg ing :貨物標記和編號，如 適用，組件的識別符 號或登記號：Marks & Nos, of the Goods, if appli

2、cable, iden tificati onorregistration number(s) Of the un it正確運輸名稱*、危險類別 包裝類*、包件的種類和數(shù)量、閃點C(閃杯)*、控制及應急溫度*、貨物 為海洋污染物*、應急措施編號*Proper shipp ing n ame*,IMO hazard class/ divisi on, UN n umber,packag inggroup*, number and kind of packages, flash point ( C c.c.),controlandemergency temperature*, identifica

3、tion of the goods as MARINE POLLUTANT*, Ems No.*、危規(guī)編號;總重(kg) 凈重/凈量Total weight (kg) Net weight (kg)*僅使用專利商標/商品名稱是不夠的，如適合：(1應在品名前加“廢棄物” ；(2) “空的未經(jīng)清潔含有殘余物上一次盛裝物”；(3)“限量” *如需要，見國際危規(guī)第2卷第346款 *需要時*Proprietary/trade names alone are not sufficient. If applicable : (1)the world ASTE should proceed name;(2)

4、” EMPTY/UNCLEANED or “ RESIDUELAST CONTAINED ;(3) ” LIMITED QUANTITY the should be added.*When required in item 3.4.6,volume 2 of the IMDG Code;*When required交付裝運貨物的形式：Goods delived as :雜貨Break bulk cargo成組件Un itized cargo box散貨包裝Bulk packages散裝固體Solid in bulk組件類型：Type of un it :集裝箱Container車輛Vehicl

5、e罐柜Portable tank開敞式Ope n “封閉式WClose如適合，在方框內(nèi)劃“x”In set “x” in appropriate box附送以下單證、資料：The followi ng docume nts(s) and in formati on are submitted: 在某種情況下，需提供特殊資料證書，詳見國際危規(guī)第 1卷第544節(jié)。in circumstan ces special in formati on certificates are required, see paragraph 5.4.4,volume 1 of IMDG Code.茲聲明：上述擬交付船

6、舶裝運的危險貨物/污染危害性貨物已按規(guī)定全部并準確地填寫了正確運輸名稱、危規(guī)編號、分類、危險性和應急 措施，需附單證齊全。包裝危險貨物，包裝正確、質(zhì)量完好；標記、 標志/標牌正確、耐久。以上申報準確無誤。Declarati on:I hereby declare that the contents of this declaration are fully and accurately described above by the proper shipp ing n ame, UN No., Class and EmS No. The goods are properly packaged,

7、 marked, labeled/ placarded and are in all respects in good con diti on for tran sport by sea.申報人員姓名：申報單位簽章Declarer(sig nature): Seal of Declarati on Un it申報人員培訓備案編號：年 月曰No.: Year Month Date主 管機 關簽注Remarks by the Admi ni strati on:緊急聯(lián)系人姓名、電話、傳真、電子郵箱：Emergency Contact Person s Name, Tel, Fawmad F此申報單

8、一式三份，其中兩份申報人留持和分送承運船舶，一份留主管機關存查。This declaration should be made in tripartite, one is kept by the Administration for file, and two for the declarer and the ship respectively.危險貨物安全適運申報單Declaration on Safety and Fitness of Dangerous Goods(散裝液體物質(zhì))(Bulk Liquids)發(fā)貨人(名稱、地址)：Shipper ( n ame,address )：承運人名

9、稱(或其代理人)：Carrier ( or its age nt):貨物種類(在相應的方框內(nèi)填上“X”)Kinds of goods ( Insert X in appropriate box ): 散化液化氣散裝油類Bulk chemical Liquefied gas Bulk oil船名和航次：Ship n ame & Voyage NO.:裝卸港：Port of Loading:卸貨港：Port of Discharg ing :正確運輸名稱；污染物類別；危規(guī)編號；數(shù)量；閃點(閉杯)；可燃上下限；自燃溫度；沸點；液體相對密度；蒸氣密度；蒸氣壓力(20C /37.8C);水中溶解度；粘度

10、；酸度；TLV ( ppm), LC50 ； LC5o( 口服/皮膚)；導電率(ps/m );液化溫度和壓力Proper Shipping Name ;IMO pollution Category; UN No; Quantity; Fiash Point(closed cup);Flammability Limits; Autoignition Temperature; Boiling Point; Relative Density of Liquid; Vapour Pressure; Solubility in Water; Viscosity; Acidity; TLV(ppm);LC

11、 50； LD 5o(oral/skin);Conductivity(ps/m);Temperature & Pressure of Liquefaction注：以上貨物特性根據(jù)貨物種類填寫合適項目。Remarks : Please fill in the proper colum ns with cargo properties不能僅使用貿(mào)易或?qū)＠QAccord ing to the cargo classificati on.Proprietary / trade n ames alone are not sufficie nt.附加資料：Additi onal in formati o

12、n:貨物反應性：Reactivity of the cargo :應急措施(溢漏需采取的措施、有效滅火劑、其它應急措施)：Emerge ncy measures (The measures take n for spill, effective fire exti nguishi ng age nt and other emerge ncy measures):人員防護：Pers onnel Protecti on:聲明：已按規(guī)定全部并準確地填寫了上述擬交付船舶載運的危險貨物的正確運輸名稱、危規(guī)編號、危險特Declarati on:I hereby declare that the decla

13、ration is fully and accurately dexcribed above by the proper shipping nai主管機關簽注欄：Remarks by the Admi nistratio n:me,申報員姓名：申報單位名稱(簽章)Declarer(sig nature):Name of Declare Un it (seal )申報人員培訓編號：填報日期：No.:Applyi ng Date:緊急聯(lián)系人姓名、電話、傳真、電子郵箱：Emerge ncy Con tact PersorisName, Tel, Fax and E-mail :此申報單一式三份，其中

14、兩份申報人留持和分送承運船舶，一份留主管機關存查。This declarati on should be made in tripartite, one is kept by the Admini strati on for file, and two for the declarer and the ship respectively.船名：Ship name： 國籍：Natio nality:航次：Voyage No:船舶載運污染危害性貨物申報單Declaration Form Dangerous Goods Carried By Ship(包裝/固體散裝危險貨物)(Packaged /

15、Solid in Bulk)進港始發(fā)港：ArrivalPort of Departure:出港作業(yè)泊位：DepartureBerth:抵港時間：Time of Arrival: 裝貨時間：Time of Load ing:貨物正確運輸名稱Proper Shipp ing Name of the Goods類別/性質(zhì)Class/Prope rty危規(guī)編號UN No.裝運形式MeansofTran sport件數(shù)NumberofPackages總重量Weight inTotal卸貨港PortofDischarg ing裝載位置Locati onofStowage備注Remarks茲聲明根據(jù)船舶裝載

16、危險貨物安全和防污染規(guī)定，本輪具備裝載上述貨物的適裝條件，貨物配裝符合要求，貨物資 料齊全。申報內(nèi)容正確無誤。I hereby declare that , in accordanee with the provisions of the safe transportation of dangerous goods by ships and pollute prevention , the ship has met the requirements of fitness for carrying the above declared goods ; Cargo stowage is prop

17、pla nned accordi ng to the requireme nts ; The docume ntatio n of the cargo is complete and the contents of the declarati on ar and correct.附送以下單證、資料：The follow ing docume nts and in formatio n are submitted in additi on.船長/申報人員：船舶/代理人(蓋章)Master/declarer:Ship /Age nt (Seal):船長證書編號/申報人員培訓備案編號：日期：Cert

18、ificate No:Date:主管機關簽證欄)Remarks by the Administration erle tru緊急聯(lián)系人姓名、電話、傳真、電子郵箱：Emerge ncy Con tact Persofe Name, Tel, Fax and E-mail :Man ager:此申報單一式三份，其中兩份申報人留持和分送港口作業(yè)部門，一份留主管機關存查。This declaration should be made in tripartite, one is kept by the Administration for file, and two for the declarer a

19、nd port operator respectively.船舶載運污染危害性貨物申報單船名： 抵港時間：Ships n ame of Arrival: 所有人： 裝貨時間：Own er:Loadi ng:Declaration Form For Dangerous Goods Carried By Ships(散裝液體物質(zhì))(Bulk Liquids )國 籍： 二Nati on ality:Voyage No.國 籍:進港始發(fā)港:Berth ingIZZIDeparturePort of Departure:Berth:岀港Time作業(yè)泊位:Time of貨物正確運輸名稱Proper Sh

20、ippingName of The Goods種類/性質(zhì)Category/ property危規(guī) 編號UNNo.數(shù)量Quantity液貨艙編號Number oftanks液艙惰化(是/否)Tank inerting (yes/no)裝卸貨物溫度(C)Cargo HandlingTemperature( C )裝/卸貨港Port ofLoading/ Discharging備注Remarks本輪液艙中存有下述壓載水/污水:艙室編號Tank No.水質(zhì)種類kinds of water數(shù)量Quantity注明該艙室為專用/清潔壓載艙或液貨艙Indicating whether the tank is

21、 segrogted/ clean ballast tank or cargo tank備注RemarksThe ballast/bilge water rema ined in tanks on board:1.清洗液貨艙作業(yè)（水洗） 是/ 否是/否2.使用清潔劑/添加劑洗艙tank washing (water wash)YesNotank washi ng by deterge nt / additivesYesNo3.原油洗艙 是/ 否是/否4.驅(qū)氣作業(yè)crude oil washing YesNoYesNogasfree ingapplicati on will be submitt

22、ed separately噸（M ）本輪準備在港口進行下述作業(yè)，并將按規(guī)定另行申請：This ship pla ns to carry out the follow ing operati on(s) in port and accord ing to the releva nt provisi ons:5.向港口接收設施排放含油/有害物質(zhì)的洗艙水/混合物、預計disposal of tank wash ing water/ water con tahn ing harmful substa nces/mixtures into port recepti on facilities, estimated quantity tons (M )茲聲明本輪裝載貨物安全與防污染證書及文書齊備，船舶構造、設備與布置具 備裝載上述貨物的適裝條件并情況正常，貨物資料齊全，申報內(nèi)容正確無誤。This is to declare that this ship certificates concerning safe tran sportati on and polluti o