船舶載運(yùn)污染危害性貨物申報(bào)單

1、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: Manager: Departure Berth: Time of Loading: 貨物正確運(yùn)輸名稱Proper Shipping Na

2、me of the Goods類別/性質(zhì)Class/Property危規(guī)編號(hào)UN No.裝運(yùn)形式Means of Transport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 declare that , in accordance with the provisions of the safe trans

3、portation 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 of the cargo is complete and the contents of the declaration are t

4、rue 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)系人姓名、電話、傳真、電子郵箱：Emergency Contact Persons Name, Tel, Fax and E-mail :

5、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 Goods 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：Shi

6、ps 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)Number of tanks液艙惰化（是/否）Tank inerting (yes/no)裝卸貨物溫度（）Cargo Handling

7、 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 ballast 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 p

8、lans 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 detergent / additives Yes No3.原油洗艙 是 / 否 4.驅(qū)氣作業(yè) 是 / 否 crude oil washing Yes

9、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 cer

10、tificates concerning safe transportation and pollution Prevention are all valid and complete; the ships construction, equipment and arrangements are in good condition and meet the requirements of fitness for carrying the above declared goods; the documentation of goods is complete and the declaratio

11、n is ture and correct.附送以下單證、資料：The following document(s) 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：Certiticate No: Date:主管機(jī)關(guān)簽證欄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