船舶载运污染危害性货物申报单（包装固体散装污染危害性货物）.pdf

船舶载运污染危害性货物申报单 Declaration Form Hazardous Goods Carried By Ship （包装/固体散装污染危害性货物） （Packaged / Solid in Bulk） 船 名：XXXX 航 次： 14000W Ship’s name： Voyage No: 国 籍： 中国 经营人： XX 公司 Nationality: Manager: 货物正确运输名称 类别/性质 Proper Shipping Name of the Class/Prope 危规编号 UN No. Goods rty Acetone(Acetone Solutions) 3 1090 进港 始发港: 南京 Arrival Port of Departure: 出港 ☑ 作业泊位: XXXX Departure Berth: 装运形式 件 数 总重量 Means of Number of Weight in Transport Packages Total 集装箱 1 0.0013 吨 抵港时间：XXXX.XX.XX Time of Arrival: 装货时间：XXXX.XX.XX Time of Loading: 卸货港 装载位置 Port of Location of 备注 Remarks Discharging Stowage SCT6 340382 兹声明根据船舶装载污染危害性货物安全和防污染规定，本轮具备装载上述货物的适装条件，货物配装符合要求， 主管机关签证栏 货物资料齐全。申报内容正确无误。 I hereby declare that , in accordance with the provisions of the safe transportation of dangerous goods by ships and pollut Remarks by the Administration prevention , the ship has met the requirements of fitness for carrying the above declared goods ; Cargo stowage is prope planned according to the requirements ; The documentation of the cargo is complete and the contents of the declaration are t and correct. 附送以下单证、资料： The following documents and information are submitted in addition. 船长/申报人员： 李四 Master/declarer: 船长证书编号/申报人员培训备案编号： Certificate No: 14000 船舶/代理人（盖章） Ship / Agent (Seal): 日期：XXXX.XX.XX Date: 紧急联系人姓名、电话、传真、电子邮箱：张三 1380000000 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 the Administration for file, and two for the declarer and port operator respectively. 1