危險(xiǎn)貨物污染危害性貨物安全適運(yùn)聲明書

1、危險(xiǎn)貨物/污染危害性貨物安全適運(yùn)聲明書Declaration on Safety and Fitness of Dangerous Goods / Hazardous Goods（包裝貨物）（Packaged）進(jìn)港Arrival/出港Departure發(fā)貨人：Shipper：收貨人：Consignee:承運(yùn)人Carrier船名和航次 ：Ships name & Voyage NO. :裝卸港：Port of Loading:卸貨港：Port of Discharging :貨物標(biāo)記和編號(hào)，如適用，組件的識(shí)別符號(hào)或登記號(hào)：Marks & Nos, of the Goods, if

2、 applicable, identification or registration number(s) Of the unit正確運(yùn)輸名稱*、危險(xiǎn)類別、危規(guī)編號(hào)；包裝類*、包件的種類和數(shù)量、閃點(diǎn)（閃杯）*、控制及應(yīng)急溫度*、貨物為海洋污染物*、應(yīng)急措施編號(hào)* Proper shipping name*,IMO hazard class/ division, UN number, packaging group*, number and kind of packages, flash point (c.c.),control and emergency temperature*, ident

3、ification of the goods as MARINE POLLUTANT*, Ems No.* 總重（kg）凈重/凈量Total weight (kg)Net weight (kg)交付裝運(yùn)貨物的形式：Goods delived as : 雜貨 Break bulk cargo 成組件 Unitized cargo box 散貨包裝 Bulk packages 散裝固體Solid in bulk組件類型：Type of unit : 集裝箱Container 車輛 Vehicle罐柜Portable tank開敞式 Open 封閉式 Close如適合，在方框內(nèi)劃“×”In

4、set“×”in appropriate box*僅使用專利商標(biāo)/商品名稱是不夠的，如適合：（1）應(yīng)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3.4.6 款 *需要時(shí)*Proprietary/trade names alone are not sufficient. If applicable : (1)the world “WASTE” should proceed name;(2)”EMPTY/UNCLEANED” or “RESIDUE-LAST CONTAINED”;(3)”LIMITED QUANTITY”

5、 the should be added.*When required in item 3.4.6,volume 2 of the IMDG Code;*When required附送以下單證、資料：The following documents(s) and information 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5.4.4節(jié)。In certain circumstances special information certificates are required, see paragraph 5.4.4,volume 1 of IMDG

6、Code.茲聲明：上述擬交付船舶裝運(yùn)的危險(xiǎn)貨物/污染危害性貨物已按規(guī)定全部并準(zhǔn)確地填寫了正確運(yùn)輸名稱、危規(guī)編號(hào)、分類、危險(xiǎn)性和應(yīng)急措施，需附單證齊全。包裝危險(xiǎn)貨物，包裝正確、質(zhì)量完好；標(biāo)記、標(biāo)志/標(biāo)牌正確、耐久。以上申報(bào)準(zhǔn)確無誤。Declaration: I hereby declare that the contents of this declaration are fully and accurately described above by the proper shipping name, UN No., Class and EmS No. The goods are properl

7、y packaged, marked, labeled/ placarded and are in all respects in good condition for transport by sea.申報(bào)人員姓名： 申報(bào)單位簽章Declarer(signature): Seal of Declaration Unit申報(bào)人員培訓(xùn)備案編號(hào)： 年 月 日No.: Year Month Date主管機(jī)關(guān)簽注欄：Remarks by the Administration:緊急聯(lián)系人姓名、電話、傳真、電子郵箱：Emergency Contact Persons Name, Tel, Fax and

8、E-mail :此申報(bào)單一式三份，其中兩份申報(bào)人留持和分送承運(yùn)船舶，一份留主管機(jī)關(guān)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(xiǎn)貨物/污染危害性貨物安全適運(yùn)聲明書Declaration on Safety and Fitness of Dangerous Goods / Hazardous Goods（散裝液體物質(zhì)）（Bulk Liquids）進(jìn)港A

9、rrival/出港Departure發(fā)貨人（名稱、地址） ：Shipper ( name,address ) ：承運(yùn)人名稱（或其代理人）：Carrier ( or its agent) ：貨物種類 （在相應(yīng)的方框內(nèi)填上“×”）Kinds of goods ( Insert “×”in appropriate box )：散化 液化氣 散裝油類Bulk chemical Liquefied gas Bulk oil 船名和航次 ：Ships name & Voyage NO. :裝卸港：Port of Loading:卸貨港：Port of Discharging :

10、正確運(yùn)輸名稱；污染物類別；危規(guī)編號(hào)；數(shù)量；閃點(diǎn)（閉杯）；可燃上下限；自燃溫度；沸點(diǎn)；液體相對密度；蒸氣密度；蒸氣壓力（20/37.8） ；水中溶解度；粘度；酸度；TLV （ppm），LC50；LC50(口服/皮膚)；導(dǎo)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;

11、 Vapour Pressure; Solubility in Water; Viscosity; Acidity; TLV(ppm);LC50；LD50(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(xiàng)目。Remarks : Please fill in the proper columns with cargo properties 不能僅使用貿(mào)易或?qū)＠Q According to the cargo classification. Proprietary

12、 / trade names alone are not sufficient.附加資料：Additional information:貨物反應(yīng)性：Reactivity of the cargo :應(yīng)急措施（溢漏需采取的措施、有效滅火劑、其它應(yīng)急措施）：Emergency measures (The measures taken for spill, effective fire extinguishing agent and other emergency measures):人員防護(hù)：Personnel Protection:聲明：已按規(guī)定全部并準(zhǔn)確地填寫了上述擬交付船舶載運(yùn)的危險(xiǎn)貨物/污

13、染危害性貨物的正確運(yùn)輸名稱、危規(guī)編號(hào)、危險(xiǎn)特性等應(yīng)申報(bào)事項(xiàng)、貨物在各方面均符合安全適運(yùn)條件。以上申報(bào)準(zhǔn)確無誤。Declaration:I hereby declare that the declaration is fully and accurately dexcribed above by the proper shipping name, UN No., hazards property, etc. The goods is in all respects in good condition for transport by sea.申報(bào)員姓名： 申報(bào)單位名稱（簽章）Declarer(s

14、ignature): Name of Declare Unit (seal ): 申報(bào)人員培訓(xùn)編號(hào)： 填報(bào)日期：No.: Applying Date: 主管機(jī)關(guān)簽注欄：Remarks by the Administration:緊急聯(lián)系人姓名、電話、傳真、電子郵箱：Emergency Contact Persons Name, Tel, Fax and E-mail :此申報(bào)單一式三份，其中兩份申報(bào)人留持和分送承運(yùn)船舶，一份留主管機(jī)關(guān)存查。This declaration should be made in tripartite, one is kept by the Administrati

15、on for file, and two for the declarer and the ship respectively. 船舶載運(yùn)污染危害性貨物申報(bào)單Declaration Form Hazardous Goods Carried By Ship（包裝/固體散裝污染危害性貨物）（Packaged / Solid in Bulk）船 名： 航 次： 進(jìn)港 始發(fā)港: 抵港時(shí)間：Ships name： Voyage No: Arrival Port of Departure: Time of Arrival: 國 籍： 經(jīng)營人： 出港 作業(yè)泊位: 裝貨時(shí)間：Nationality: Mana

16、ger: Departure Berth: Time of Loading: 貨物正確運(yùn)輸名稱Proper Shipping Name of the Goods類別/性質(zhì)Class/Property危規(guī)編號(hào)UN No.裝運(yùn)形式Means ofTransport件 數(shù)Number of Packages總重量Weight in Total卸貨港Port of Discharging裝載位置Location of Stowage備注Remarks 茲聲明根據(jù)船舶裝載污染危害性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(bào)內(nèi)容正確無誤。I hereby d

17、eclare that , in accordance with the provisions of the safe transportation of dangerous goods by ships and pollution prevention , the ship has met the requirements of fitness for carrying the above declared goods ; Cargo stowage is properly planned according to the requirements ; The documentation o

18、f the cargo is complete and the contents of the declaration are true and correct.附送以下單證、資料：The following documents and information are submitted in addition.船長/申報(bào)人員： 船舶/代理人（蓋章） Master/declarer: Ship / Agent (Seal): 船長證書編號(hào)/申報(bào)人員培訓(xùn)備案編號(hào)： 日期： Certificate No: Date: 主管機(jī)關(guān)簽證欄Remarks by the Administration緊急聯(lián)系

19、人姓名、電話、傳真、電子郵箱：Emergency Contact Persons Name, Tel, Fax and E-mail :此申報(bào)單一式三份，其中兩份申報(bào)人留持和分送港口作業(yè)部門，一份留主管機(jī)關(guān)存查。This declaration should be made in tripartite, one is kept by the Administration for file, and two for the declarer and port operator respectively.船舶載運(yùn)污染危害性貨物申報(bào)單Declaration Form For Hazardous Go

20、ods Carried By Ships（散裝液體物質(zhì)）（Bulk Liquids）船 名： 國 籍： 進(jìn)港 始發(fā)港: 抵港時(shí)間：Ships name： Nationality: Berthing Port of Departure: Time of Arrival: 所有人： 航 次： 出港 作業(yè)泊位: 裝貨時(shí)間：Owner: Voyage No. Departure Berth: Time of Loading: 貨物正確運(yùn)輸名稱Proper Shipping Name of The Goods種類/性質(zhì)Category/property危規(guī)編號(hào)UN No.數(shù) 量Quantity液貨艙編號(hào)

21、Number of tanks液艙惰化（是/否）Tank inerting (yes/no)裝卸貨物溫度（）Cargo Handling Temperature()裝/卸貨港Port of Loading/ Discharging備注Remarks本輪液艙中存有下述壓載水/污水：The ballast/bilge water remained in tanks on board:艙室編號(hào)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 segrogted/ clean bal

22、last tank or cargo tank備 注Remarks本輪準(zhǔn)備在港口進(jìn)行下述作業(yè)，并將按規(guī)定另行申請：This ship plans to carry out the following operation(s) in port and application will be submitted separately according to the relevant provisions:1.清洗液貨艙作業(yè)（水洗） 是 / 否 2.使用清潔劑/添加劑洗艙 是 / 否 tank washing (water wash) Yes No tank washing by detergen

23、t / additives Yes No3.原油洗艙 是 / 否 4.驅(qū)氣作業(yè) 是 / 否 crude oil washing Yes No gas freeing Yes No5.向港口接收設(shè)施排放含油/有害物質(zhì)的洗艙水/混合物、預(yù)計(jì) 噸（M3） disposal of tank washing water/ water containing harmful substances/mixtures into port reception facilities, estimated quantity tons (M3)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(gòu)造、設(shè)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(bào)內(nèi)容正確無誤。This is to declare that this ships certificates concernin