船舶载运危险货物申报单 Declaration Form For Dangerous Goods Carried By Ship (散装液体货物) (Liquid in Bulk) 船名: 国籍: □进港始发港: 抵港时间: Ship ’s Name: _____ __ ___ Nationality:________ ___ Berth ing Port of Departure:______ ____ _ Time of Arrival:______ ___ _ 所有人: 航次: □出港作业泊位: 装货时间: Owner: _________ ______ Voyage No.:_______ ___ _ Departure Berth: ____________ ________ Time of Loading:_____ ___ _ 货物正确运输名称 Proper Shipping Name of the Goods 种类/性质 C atagory / Property 危规编号 UN No. 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(℃) Cargo Handling Temperature (℃) 装/ 卸货港 Port of Loading / Discharging 备注 Remarks 本轮液舱中存有下述压载水/污水: The ballast/bilge water remained in tanks on board: 舱室编号 Tank No. 水质种类 Kinds of water 数量 Quantity 注明该舱室为专用/ 清洁压载或液货舱 Indicating whether the tank is segrogted/ clean ballast tank or cargo tank 备注 Remarks 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 the relevant provisions: (水洗) □是/□否 □是/□否 tank washing ( water wash) Yes No tank washing by detergent/ additives Yes No □是/□否 □是/□否 crude oil washing Yes No gas freeing Yes No 、预计? ?__________ 吨( M 3) disposal of tank washing water/ water containing harmful substance
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