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1、船舶载运危险货物申报行政审批申请书船舶载运危险货物申报单船舶载运危险货物申报单 Declaration Form Dangerous Goods Carried By Ship （包装（包装/固体散装危险货物）固体散装危险货物） （Packaged / Solid in Bulk） 船 名： 航 次： 进港 始发港: 抵港时间： Ships name： Voyage No: Arrival Port of Departure: Time of Arrival: 国 籍： 经营人： 出港 作业泊位: 装货时间： Nationality: Manager: Departure Berth: Tim
2、e of Loading: 货物正确运输名称 Proper Shipping Name of the Goods类别/性质 Class/Prope rty危规编号 UN No.装运形式 Means of Transport件 数 Number of Packages总重量 Weight in Total卸货港 Port of Discharging装载位置 Location of Stowage备注 Remarks兹声明根据船舶装载危险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，货物资 料齐全。申报内容正确无误。 I hereby declare that , in
3、 accordance with the provisions of the safe transportation of dangerous goods by ships and pollution prevention , the ship has met the requirements of fitness for carrying the above declared goods ; Cargo stowage is properly planned according to the requirements ; The documentation of the cargo is c
4、omplete and the contents of the declaration are true 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： 船舶/代理人（盖章） Master/declarer: Ship / Agent (Seal): 船长证书编号/申报人员培训备案编号： 日期： Certificate No: Date: 主管机关签证栏 Remarks by the Administration紧急联系人姓名、电话、传真、电子邮
5、箱： Emergency Contact Persons 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.船舶载运危险货物申报单船舶载运危险货物申报单Declaration Form For Dangerous Good
6、s Carried By Ships （散装液体物质） （Bulk Liquids） 船 名： 国 籍： 进港 始发港: 抵港时间： Ships name： Nationality: Berthing 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: 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
7、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 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:
8、 1.清洗液货舱作业（水洗） 是 / 否 2.使用清洁剂/添加剂洗舱 是 / 否tank washing (water wash) Yes No tank washing by detergent / additives Yes No 3.原油洗舱 是 / 否 4.驱气作业 是 / 否crude oil washing Yes No gas freeing Yes No 5.向港口接收设施排放含油/有害物质的洗舱水/混合物、预计 吨（M3）disposal of tank washing water/ water containing harmful substances/mixtures i
9、nto port reception facilities, estimated quantity tons (M3)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 ships certificates concerning safe transportation and pollution Prevention are all valid and complete; the ships construction, equipment and a
10、rrangements are in good condition and meet the requirements of fitness for carrying the above declared goods; the documentation of goods is complete and the declaration is ture and correct.附送以下单证、资料：The following document(s) and information are submitted in addition:船长/申报人员： 船舶/代理人（盖章）Master/declare
11、r: Ship / Agent (Seal)船长证书编号/申报人员培训备案编号： 日期：Certiticate No: Date:主管机关签证栏 Remarks by the Administration紧急联系人姓名、电话、传真、电子邮箱： Emergency Contact Persons 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.货物正确运输名称 Proper Shipping Name of The Goods种类/性质 Category/ 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
