XX宽减计划申请3

XXXX宽减计划申请宽减计划申请3 3 1香港特別行政區政府The Governmentof Hong Kong SpecialAdministrative Region遠洋船舶在香港泊岸時使用清潔燃油的港口設施及燈標費寬 減計劃Port Facilitiesand LightDues Incentive Scheme forOcean GoingVessels UsingCleaner FuelWhile Berthingin Hong Kong泊岸轉油聲明Fuel Switching Declaration Form本表格和有關文件必須在船隻離開香港水域後3天內遞交到海事 處 船隻代理人或船長可透過海事處的電子業務系統 傳真 852 25438299或親臨香港統一碼頭道38號海港政府大樓3樓東翼307 室 1 2號櫃台 遞交所需文件 This pletedform and the supporting document must be submitted to the Marine Department within3days afterthe vesselleaving Hong Kong waters The shipping agent orshipmaster cansubmit this form and the requireddocument to the Marine Department byElectronic BusinessSystem eBS fax at 852 25438299or counterservice atcounter1and2of Room307 3 F East Wing Central Marine Office Harbour Building 38Pier Road Hong Kong 第一部Part I參與船隻資料Particulars ofVessel船名Name ofVessel船籍Nationality ofVessel呼號Call Sign船隻類型Type ofVessel海事處申請編號MD ApplicationNumber環保署登記編號EPD RegistrationNumber國際海事組織編號IMO Number 第二部Part II船隻代理人資料Particulars of Shipping Agent船隻代理人名稱Name ofShipping Agent船隻代理人地址Address ofShipping Agent聯絡人Contact Person電話Telephone流動電話號碼Mobile PhoneNo To Director of Marine the Director on behalfof theHKSAR Government the Government 致 海事處處長 處長 代表香港特 別行政區政府 政府 為支持我 我們申請港口設施及燈標費寬減計劃 寬減計劃 的申請 我 我們現為以上船隻遞交泊岸轉油聲明 我 我們明白船隻代理人 船長必須在船隻離開香港水域後3天內 向 傳真Fax電郵Email申請編號Application No 表格三Form32海事處處長遞交以下文件 a 由船隻代理人及船長 簽妥的泊岸轉油聲明 顯示船隻抵岸及離岸時的轉油時間 當中 船長承諾及聲明 部份須在船員見證下簽署 即本表格 b 交付單 的日期必須在抵達香港前6個月之內 及 c 在船員見證下 由輪機 長簽署並由船長加簽的有關機艙日誌的核證副本 當中必須顯示船 隻在泊岸期間轉用含硫量不逾0 5 的燃油 由船長在船員見證下簽署的最近一次含硫量不逾0 5 的燃油交付單 核證副本 該In supportof my our application for thegrant of the Concession under thePort Facilitiesand LightDues Incentive Scheme the Incentive Scheme I we herebysubmit theFuel SwitchingDeclaration Formfor theabove vessel Vessel I we understand that theshipping agent shipmaster of the Vesselhave to submit to the Director of Marihe followingdocuments within3days afterthe Vesselleaving Hong Kong waters a Completed Fuel SwitchingDeclarationForm signed by theshippingagentand shipmasterrespective indicating thefuel switchovertime uponarrival anddeparture fromberth The sectionof Undertaking andDeclaration by the shipmaster must besigned underwitness ofan onboardcrew member This Form b witness ofan onboardcrew membershowing thelast deliveryof fuel with sulphur content not more than0 5 The dateof theBDN shallbe within6months beforethe arrival at Hong Kong and c Certified true copy ofEngine RoomLog Booksigned by the ChiefEngineer andcounter signed bythe shipmasterunder thewitness ofan onboardcrew member which indicatesthat the Vessel hasswitched tofuel with sulphur content not more than0 5 while at berth inHongKong waters Certified truecopy ofBunker DeliveryNote BDN signed bythe shipmasterunder the日期Date 代理人簽署及公司印鑑 Signature andCompany Stamp 若燃油交付單的日期未能符合 抵達香港前6個月的期限 船長可提交補充資料予海事處作酌情處理 If theBDN cannotmeet thecriteria of within6months beforearrivalatHongKong the shipmastermay submitsupplementary information to theMarine Departmentto justifythe case 若船長直接遞交此表格予海事處 則無須簽署此部份 但必 須提供船隻代理人資料 No signatureis requiredif the shipmaster submitsthis Formto MarineDepartment direct However the particularsofShippingAgent shallbe provided 第三部Part III船長承諾及聲明書Undertaking andDeclaration bythe Shipmaster船長姓名Name ofShipmaster國籍Nationality出生日期Date ofBirth護照號碼Passport Number3To DirectorofMarine the Director on behalfof theHKSAR Government the Government 致 海事處處長 處長 代表香港特 別行政區政府 政府 鑑於處長同意考慮給予本船隻此寬減計劃內的 減免 我以船長身份作出以下承諾及聲明 In considerationof youragreeing toconsider thegrant of Concessionunder the Incentive Scheme in respect of the Vessel I as theshipmaster of the Vessel hereby undertakeand declarethat 1 我確認本船隻在船上載有含硫量不逾0 5 的燃油 最近一次交付 燃油的詳情如下I confirmthat theVessel hascarried fuel with sulphur content not more than0 5 on board The detailsof thelast deliveryare asfollows 低硫燃油資料Details ofLow SulphurFuel 最近一次交付Last delivery 供給燃油港口燃油交付日期Bunkering PortDate ofBunker Delivery數量 公噸 含硫量Sulphur Content2 我確認本船隻在下述泊岸期間 其輔助引擎 發電機及鍋 爐均已轉用含硫量不逾0 5 的燃油 並附上在船員見證下 由輪機 長簽署並由船長加簽的有關機艙日誌的核證副本 顯示船隻在泊岸 期間轉用含硫量不逾0 5 的燃油 I confirmthat theVessel switched to use fuelwithsulphurcontentnotmorethan0 5 in allauxiliary engines generators and boilersduring thefollowing berthingperiod I alsoattach the certified truecopy ofEngine RoomLog Booksigned bythe ChiefEngineer andcounter signedbytheshipmasterunder thewitness ofan onboardcrew member which indicatesthat theVessel hasswitched tousefuelwithsulphurcontentnotmorethan0 5 while atberth inHongKongwaters 泊岸資料Berthing Details Quantity Metric Tons 日期 日 月 年 Date dd mm yyyy 本地時間Local Time泊岸地點Berthing Location 泊岸時間Arrival Time at Berth 泊岸 轉油時間Arrival atBerth Fuel SwitchTime離岸 轉油時間Departure from Berth FuelSwitchTime離岸時間Departure Time fromBerth 泊岸轉用低硫燃油時間 小時 Duration forusing lowsulphur fuelwhile berthing hr 低硫燃油消耗 公噸 Low sulphur fuel consumed Metric Tons 43 我明白任何政府人員及 或其代表有權查核相關文件 包括 但不限於燃油交付單 油類記錄簿及機艙日誌 以核證船隻泊岸時 轉用低硫燃油 並同意保留上述文件最少一年以供查核 我同意在政府人員或其代表提出要求時 在七個工作天內提交有關 文件的核證副本及 或進一步資料作查核之用 憑藉簽署本表格 我同意政府人員及 或其代表可登船查核任何有關 泊岸轉用低硫燃油的文件 及 或有權抽取燃油樣本 以核實任何有 關申請寬減計劃內的減免之用 我會彌償政府任何有關此申請寬減的損失 I understandthat anyGovernment officialand or his representative hasthe rightto conductdocument checkto verifythe useof lowsulphurfuelwhile theVessel isatberthand agreeto keepthe relevant documents including notbut limitedtotheBunker DeliveryNote Oil RecordBook andEngine RoomLog Bookfor atleast oneyear forinspection Upon request I agreetosubmitthecertifiedtruecopyof therelevantdocumentsand or furtherinformationtothe Government official or his representativefor verificationwithin sevenworking days By virtueof signingthis form I herebygive myconsent tothe Governmentthat the Governmentofficialand orhisrepresentative mayboard theVessel toinspect anydocument reasonablyrequired and or takefuel oilsample for the purposeof verificationof anymatter relevanttotheapplicationforor grant ofConcessionunder the IncentiveSchemeinrespectof theVessel I shallindemnify orkeep indemnifiedthe Governmentof anyloss arisingtherefrom orin connectiontherewith thisIncentiveScheme 4 我明白倘船長未能在政府人員或其代表要 求下提交有關文件及 或進一步資料證明本船隻泊岸時轉用含硫量不 逾0 5 的燃油 海事處處長可追討已減免的港口設施及燈標費用 如 本船隻已獲減免 並保留追究責任的權利 I understandthat incase theshipmaster failsto producesupporting documentsand or furtherinformation asrequested bytheGovernmentofficial orhisrepresentativeto provethat theVessel hasswitchedtofuelwithsulphurcontentnotmorethan0 5 while atberth the DirectorofMarinemay requestthe refundoftheremitted portfacilities andlight dues if theVessel hasreceived relevantreduction indues and reservesthe rightto pursuefurther 5 我完全知悉根據 盜竊罪條例 香港法例第210 章 包括第16條A 欺詐罪 和第18條B 以欺騙手段逃避法律責任 所 訂立的嚴重罪行 我完全明白任何人使用虛假資料以申請寬減計劃內的減免 可能會 被起訴 I amfully awareoftheserious offencesunder theTheft Ordinance Chapter210oftheLaws ofHongKong including sections16A Fraud and18B Evasion ofliability bydeception I alsounderstandthatany personthat usesfalse informationto applyforthegrantofa ConcessionundertheIncentiveSchememay beliable forprosecution6 我已小心閱讀承諾及聲明書的內容 並完全明白 根據本承諾及聲明書的義務及法律責任 I havecarefully readthe provisionsof thisUndertaking andDeclaration andfully understandits obligationsand liabilities 7 我明白此表格連同所需文件 必須在船隻離開香港 水域後3天內 遞交到海事處 方為有效 I understandthat this form togetherwith thesupportingdocumentmustbesubmittedtotheMarineDepartmentwi thin3days aftertheVesselleaving HongKongwaters 日期Date船長簽署及船隻印鑑Signature ofShipmaster andShip Stamp5見證Witness第三部 船長承諾及聲明書 是由船長在以下見 證人前簽立 Part III Undertaking andDeclaration byShipmaster is signedbytheShipmaster inthe presenceofthewitness 見證人姓名Name ofWitness國籍Nationality出生日期Date ofBirth護照號碼Passport Number日期Date見證人簽署Signature ofWitness收集個人資料的目的Purpose ofCollection ofPersonal Data1 此表格內所報的個人資料 會供海事處及環境保護署作處理 港口設施及燈標費寬減計劃的申請之用 該等資料有可能會轉交其他部門或機構以供調查 檢控之用 The personaldata providedin thisform willbe usedbytheMa