-
危险货物
/
污染危害性货物安全适运声明书
p>
Declaration on Safety and
Fitness of Dangerous Goods /
Hazardous
Goods
(包装货物)
(
Packaged
)
进港
Arrival
□
/
出港
Departure
□
发货人:
收货人:
承运人
Consignee:
Carrier
Shipper
:
船名和航次
:
装卸港:
卸货港:
Ship’s name
& V
oyage NO. :
Port of Loading:
Port of Discharging :
货物标记和编号,如
正确运输名称
*
、危险类别、危规编号;
总重(
kg
< br>)
交付装运货物的形式:
Goods delived as :
适用,组件的识别符
包装类
**
、包件的种类和数量、闪点
℃
净重
/
净量
□
杂货
号或登记号:
(闪杯)
**
、控制及应急温度
**
、货物
Total weight (kg)
Net
weight (kg)
Break bulk cargo
Marks
&
Nos,
of
the
为海洋污染物
**
、应急措施编号
***
□
成组件
Goods,
if
applicable,
Proper
shipping
name*,IMO
hazard
class/
identification
or
division,
UN
number,
packaging
group**,
Unitized cargo box
registration
number(s)
number
and
kind
of
packages,
flash
point
□
散货包装
Of the unit
Bulk packages
(
℃
c.c.),control
and
emergency
□
散装固体
temperature**,
identification
of
the
goods
as
MARINE
POLLUTANT**,
Ems
Solid in bulk
No.***
组件类型:
Type of
unit :
□集装箱
Container
□车辆
Vehicle
□罐柜
*
仅使用专利商标
/
商品
名称是不够的,如适合:
(
1
)应在品
名前加“废弃物”
;
(
2
)
Portable tank
□开敞式
“空的未经清洁含有残余物
-上一次盛装物”
;
(
3
)
“限量”
**
如需要,见
《国际危
Open
规》第
2
卷第
3.4.6
款
***
需要时
*Proprietary/trade names alone are not
sufficient. If applicable : (1)the world
“W
ASTE”
□封闭式
should
proceed
name;(2)”EMPTY/UNCLEANED”
or
“RESIDUE
-LAST
Close
CONTAINED”;(3)”LIMITED QUANTITY”
the
should be
added.**When required
如适合,
在方
框内划
“×”
Inset“×”in appropriate
box
in item 3.4.6,volume 2
of the IMDG Code;***When required
附送以下单证、资料:
The
following documents(s) and information are
submitted:
在某种情况下,需提供特殊资料证书,详见《国际危规》第
p>
1
卷第
5.4.4
节。
in circumstances special
information certificates are required, see
paragraph 5.4.4,volume 1 of IMDG Code.
兹声明:
主管机关签注栏:
上述拟交付船舶装
运的危险货物
/
污染危害性货物已按规定全
Remarks by the Administration:
部并准确地填写了正确运输名称、危规编号、分类、危险性和应急
措施,需附
单证齐全。包装危险货物,包装正确、质量完好;标记、
标志
/
标牌正确、耐久。以上申报准确无误。
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
properly
packaged,
marked,
labeled/
placarded and are in all respects in
good condition for transport by sea.
申报人员姓名:
申报单位签章
Declarer(signature):
Seal of Declaration Unit
申报人员培训备案编号:
年
月
日
No.:
Year
Month
Date
紧急联系人姓名、电话、传真、电子邮箱:
Emergency Contact Person’s Name, Tel,
Fax
and E-mail :
此申报单一式三份,其中
两份申报人留持和分送承运船舶,一份留主管机关存查。
This declaration should be made in
tripartite, one is kept by the Administration for
file, and two for the declarer and the ship
respectively.
<
/p>
危险货物
/
污染危害性货物安全适运声明
书
Declaration on Safety and
Fitness of Dangerous Goods /
Hazardous
Goods
(散装液体物质)
(
Bulk
Liquids
)
进港
Arrival
□
/
出港<
/p>
Departure
□
发货人(名称、地址)
:
Shipper (
name,address )
:
货物种类
(在相应的方框内填上“×”
)
Kinds of goods ( Insert
“
×
”
in
appropriate box )
:
□散化
□液化气
□散装油类
Bulk chemical
Liquefied gas
Bulk oil
承运人名称(或其代理人)
:
Carrier ( or its agent)
:
船名和航次
:
Ship
’
s name &
V
oyage NO. :
装卸港:
卸货港:
Port of
Loading:
Port of Discharging
:
正确运输名称※;污染物类别;危规编号;数量;闪点(闭杯)
;可燃上下限;自燃温度;沸点;液体相对密度;蒸
气密度;
蒸气压力
(
20
℃
< br>/37.8
℃)
;
水中溶解度;
粘度;
酸度;
TLV
(
ppm
)
,
LC
50
;
LC
50
(
口服
/
皮肤
)
;
导电率
(
ps/m
)
;
液化温度和压力
Proper
Shipping
Name
※
;IMO
pollution
Category;
UN
No;
Quantity;
Fiash
Point(closed
cup);Flammability
Limits;
Autoignition Temperature; Boiling
Point; Relative Density of Liquid;
V
apour Pressure; Solubility in Water;
Viscosity; Acidity;
TLV(ppm);LC
< br>50
;
LD
50
(oral/skin);Conductivity(ps/m);Temperature &
Pressure of Liquefaction
注:以上货物特性根据货物种类填写合适项目。
Remarks : Please fill in the proper
columns with cargo properties
※不能仅使用贸易或专利名称
According to the cargo classification.
Proprietary / trade names alone are not
sufficient.
附加资料:
Additional information:
货物反应性:
Reactivity
of the cargo :
应急措施(溢漏需采取的措
施、有效灭火剂、其它应急措施)
:
Emergency measures (The measures taken
for spill, effective fire extinguishing agent and
other emergency measures):
人员防护:
Personnel
Protection:
声明:
主
管
机
关
签
p>
注
栏
:
已按规定全部并准确地填写了上述拟交付船舶载运的危险货物
/
污染危害性货
Remarks by the
Administration:
物的正确运输名称、危规编号、危险特性等应申报事
项、货物在各方面均符合安
全适运条件。以上申报准确无误。
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.
申报员姓名:
申报单位名称(签章)
Declarer(signature):
Name of Declare Unit (seal ):
申报人员培训编号:
填报日期:
No.:
Applying Date:
紧急联系人姓名、电话、传真、电子邮箱:
Emergency Contact
Person
’
s Name, Tel, Fax and
E-mail :
此申报单一式三份,其中两份申报人留持和分送承运船舶,一份留主
管机关存查。
This declaration
should be made in tripartite, one is kept by the
Administration for file, and two for the declarer
and the
ship respectively.
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