船舶载运污染危害性货物申报单

1、船舶载运污染危害性货物申报单船名：南鸿XXX Ship s name 国籍：中国Nati on ality:航 次: XXXXXXXXXVoyage No:经营人：中海XX公司Man ager:Declaration Form Hazardous Goods Carried By Ship(包装/固体散装污染危害性货物)(Packaged / Solid in Bulk)进港Arrival出港二IDeparture抵港时间：20XX年XX月XX日Time of Arrival:始发港：香港Port of Departure:作业泊位：海口港XX号泊位装货时间：20XX年XX月XX日Berth:

2、Time of Load ing:货物止确运输名称Proper Shipp ing Name of the Goods类别/性质Class/Prope rty危规编号 UN No.装运形式MeansofTran sport件数NumberofPackages总重量Weight in Total卸货港PortofDischar ging装载位置Locati onofStowage备注Remarks四氯化硅8类1818集装箱2个罐柜43.95 吨海口港一舱底层SILILONTETRALHLORIDE箱号：TCVU8910958TCVU8910957兹声明根据船舶装载污染危害性货物安全和防污染规定，

3、本轮具备装载上述货 货物资料齐全。申报内容正确无误。I hereby declare that , in accorda nee with the provisi ons of the safe tran sport, prevention , the ship has met the requirements of fitness for carrying the a planned according to the requirements ; The documentation of the cargo is c( and correct附送以下单证、资料：货物理化性质、货物积载图、舱单

4、、船舶危险品适装证The follow ing docume nts and in formatio n are submitted in additi on.船长/申报人员：张三船舶Master/declarer:Ship船长证书编号/申报人员培训备案编号：日期Certificate No:10023( S)Date物的适装条件，货物配装符合要求，ation of dan gerous goods by ships and polluti bove declared goods ; Cargo stowage is prop )mplete and the contents of the d

5、eclarati on ar正书、船舶适航证书/代理人(盖章)：海南XX船务有限公司)/ Age nt (Seal):20XX年XX月XX日e:主管机关签证栏o Remarks by the AdministrationJerlye tru紧急联系人姓名、电话、传真、，电子邮箱：张三 XXXXXXXXEmerge ncy Con tact Pers on s Name, Tel, Faxmad E此申报单一式三份，其中两份申报人留持和分送港口作业部门，一份留主管机关存查。This declaration should be made in tripartite, one is kept by

6、the Administration for file, and two for the declarer and port operator respectivel041（散装液体物质）（Bulk Liquids ） 船名：国籍： 进港Ship s name海南 X 号Nationality: 中国Berthing所有人： 航次：岀港Owner:海南 XX 船务有限公司Voyage No._XX _ Departure舱室编号Tank No.水质种类kinds of water数量Quantity注明该舱室为专用/清洁压载舱或液货舱Indicating whether the tank is

7、 segrogted/ clean ballast tank or cargo tank备注Remarks无无无The ballast/bilge water rema ined in tanks on board:本轮准备在港口进行下述作业，并将按规定另行申请:This ship plans to carry out the following operation(s) in port and application will be submitted separately according to thereleva nt provisi ons:1.清洗液货舱作业(水洗)tank was

8、hi ng (water wash)3.原油洗舱crude oil wash ing是/否Yes是/YesNo0否No2.4.使用清洁剂/添加剂洗舱tank wash ing by deterge nt / additives驱气作业gas freei ng30吨(M )是/ 否Yesp-No是/ 否Yes No5.向港口接收设施排放含油/有害物质的洗舱水/混合物、预计disposal of tank washi ng water/ water containing armful substah nces/mixtures into port recepti on facilities, es

9、timated quantity ons (M )兹声明本轮装载货物安全与防污染证书及文书齐备，船舶构造、设备与布置具 备装载上述货物的适装条件并情况正常，货物资料齐全，申报内容正确无误。This is to declare that this ship certificates concerning safe transportation and pollution Prevention are all valid and complete; the ship s consttuand arrangementsare in good condition and meet the requir

10、ements of fitness for carry ing the above declared goods; the docume ntati on of goods is complete and the declarati on is ture and correct.附送以下单证、资料：货物理化性质、船舶适装证书主管机关签证栏Remarks by the Admi nistrati onction, equipme nThe follow ing docume nt(s) and in formati on are submitted in additi on: 船长/申报人员：船

11、舶/代理人（盖章）张三Master/declarer:船长证书编号/申报人员培训备案编号:Ship / Agen t (Seal)日期：20XX年XX月XX日船舶载运危险货物/污染危害性货物申报单Declaration Form For Hazardous Goods Carried By Ships始发港：抵港时间：Port of Departure:香港 Time of Arrival: 作业泊位：一 _装货时间：Berth:_马村新兴港码头 _ Time of Loading: 货物正确运输名称Proper ShippingName of The Goods种类/性质Category/

12、property危规 编号UNNo.数量Quantity液货舱编号Number of tanks液舱惰化(是/否)Tank inerting (yes/no)装卸货物温度(C)Cargo HandlingTemperature( C )装御货港Port ofLoading/ Discharging备注Remarks菜子油RAPE SEED OILD类30821500 吨1-3W否常温香港至 海口海洋污 染物本轮液舱中存有下述压载水/污水:Date:Certiticate No:10099 (S)紧急联系人姓名、电话、传真、电子邮箱：张三XXXXXXXXEmergency Con tact Pers on s Name, Tel, Fax-araill