1、PAGE3危險貨物安全適運申報單Declaration on Safety and Fitness of Dangerous Goods（散裝液體物質）（Bulk Liquids）發貨人(名稱、地址)：Shipper(name，address)：承運人名稱(或其代理人)：Carrier（or its agent）：貨物種類(在相應的方框內填上“”)：Kinds of goods (Insert“”in appropriate box)：散化 液化氣 散裝油類Bulk chemical Liquefied gas Bulk oil船名：Ships name：航次：Voyage NO：裝貨港：Po

2、rt of Loading：卸貨港：Port of Discharging：正確運輸名稱；污染物類別；危規編號；數量；閃點（閉杯）；可燃上下；自燃溫度；沸點；液體相對密度；蒸氣密度；蒸氣壓力（20/37.8）；水中溶解度；粘度；酸度；TLV（ppm）；LC50；LD50（口服/皮膚）；導電率（ps/m）；液化溫度和壓力 Proper Shipping Name；IMO prllution Category；UN No.；Quantity；Flash Point(closed cup)；Flammability Limits；Autoignition Temperature；Boiling Po

3、int；Relative Density of Liquid；Vapour Density；Vapour Pressure；Solubility in Water；Viscosity；Acidity；TLV(ppm)；LC50；LD50(oral/skin)；Conductivity(ps/m)；Temperature&Pressure of Liquefaction注：以上貨物特性根據貨物種類填寫合適項目。 不能僅使用貿易或專利名稱。Remarks：Please fill in the proper columns with cargo Proprietary/trade names alo

4、ne are not Properties according to the cargo classification. sufficient.附加資料：Additional informatiom：貨物反應性：Reactivity of the cargo：應急措施(溢漏需采取的措施、有效滅火劑、其他應急措施)：Emergency measures(The measures taken for spill,effective fire extinguishing agent and other emeragency measures)：人員防護：Personnel Protection：聲明

5、：已按規定全部并準確地填寫了上述擬交付船舶載運的危險貨物的正確名稱、危規編號、危險特性等應申報事項，貨物在各方面均符合安全適運條件。以上申報準確無誤。Declaration:I hereby declare that declaration is fully and accurately described above by the proper shipping name,UN No.,hazards property, goods is in all respects in good condition for transport by sea.申報員(簽字)： 申報單位名稱(蓋章)Dec

6、larer(sigmature): Name of Declare Unit(seal)申報員證書編號： 填報日期：Declarer certificate NO.: Applying Date:主 管 機 關 簽 注 欄：Remarks by the Administration:緊急聯系人姓名Emergency Contact perons Name電話Tel傳真Fax電子郵箱E-mail船舶載運危險貨物申報單Declaration Form for Dangerous Goods Carried By Ships（散裝液體貨物）(Liquid in Bulk)船 名： 國 籍： 進港 始

7、 發 港： 抵 港 時 間：Ships name: Nationality: Berthing Port of Departure: Time of Arrival:所有人： 航 次： 進港 作業泊位: 裝 貨 時 間:Owner： VoyageNo.： Departure Berth: Time of Loading:貨物正確運輸名稱Proper ShippingName of the Goods種類/性質Category/Property危規編號UN No.數 量Quanlity.液貨艙編號Number of Tanks液艙惰化Tank inerting裝卸貨物溫度（）Cargo Hand

8、ling Temperature（）裝/卸貨港Port of loading備注Remarks本輪液艙存有下述壓載水/污水：（The ballast/bilge water remained in tanks on board：）艙室編號Tank No.水質種類Kinds of water數量Quantity注明該艙室為專用/清潔壓載艙或液貨艙備注Remaks本輪準備在港口進行下述作業，并將按規定另行申請：This ship plans to carry out the following operation(s) in port and application will be submitt

9、ed separately according to the relevant provisions：清洗液貨艙作業（水洗）：Tank washing(water wash)：是 / 否Yes No使用清潔劑/添加劑洗艙：Tank washing by Detergent/additives：是 / 否Yes No原油洗艙：Crude oil washing：是 / 否Yes No驅氣作業：Gas freeing：是 / 否Yes No向港口接受設施排放含油/有害物質的洗倉水/混合物，預計（ ）噸（M3）Disposal of tank washing water/water containi

10、ng harmful substances/mixtures into port reception facilities,estimated quantity( )tons(M3)茲聲明本輪裝載貨物安全與防污染證書及文書齊備，船舶構造、設備與布置具備裝載上述貨物的適裝條件并情況正常，貨物資料齊全，申報內容正確無誤。This is to declare that this ships certificates concerning safe transportation and pollution prevention are all valid and complete;the ships

11、constrness,equipment and arrangements 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.附送以下單證、資料The following document(s) and information are submitted in addition:主 管 機 關 簽 注 欄：Remark