危险货物/ 污染危害性货物安全适运申报单 Declaration on Safety and Fitness of Dangerous Goods / Hazardous Goods
（包装货物）
（Packaged）
进港 Arrival□/出港 Departure□ 发货人：
Shipper：
收货人：
Consignee:
承运人 Carrier
船名和航次 ：
Ship’s name & Voyage NO. :
装卸港：
Port of Loading:
卸货港：
Port of Discharging :
货物标记和编号，如适用，组件的识别符号或登记号：
Marks & Nos, of the Goods, if applicable, identification or registration number(s) Of the unit
正确运输名称*、危险类别、危规编号；包装类**、包件的种类和数量、闪点℃（闪杯）**、控制及应急温度**、货物为海洋污染物**、应急措施编号***
Proper shipping name*,IMO hazard class/ division, UN number, packaging group**, number and kind of packages, flash point ( ℃ c.c.),control and emergency temperature**, identification of the goods as MARINE POLLUTANT**, Ems No.***
总重（kg）
净重/净量 Total weight (kg) Net weight (kg)
交付装运货物的形式：
Goods delived as : □ 杂货
Break bulk cargo
□ 成组件
Unitized cargo box □ 散货包装
Bulk packages □ 散装固体 Solid in bulk 组件类型：
Type of unit :
□集装箱 Container
□车辆
Vehicle □罐柜 Portable tank □开敞式
Open
□封闭式
Close 如适合，在方框内划“×” Inset“×”in appropriate box *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）“空的未经清洁含有残余物－上一次盛装物”；（3）“限量”**如需要，见《国际危规》第 2 卷第 3.4.6 款
***需要时 *Proprietary/trade names alone are not sufficient. If applicable : (1)the world “WASTE” should proceed name;(2)”EMPTY/UNCLEANED” or “RESIDUE-LAST CONTAINED”;(3)”LIMITED QUANTITY”
the should be added.**When required 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 1 卷第 5.4.4 节。
In certain circumstances special information certificates are required, see paragraph 5.4.4,volume 1 of IMDG Code. 兹声明：
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
主管机关签注栏：
Remarks by the Administration:
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.
危险 货物/ 污染危害性货物安全适运申报单 Declaration on Safety and Fitness of Dangerous Goods / Hazardous Goods
（散装液体物质）
（Bulk Liquids）
进港 Arrival□/出港 Departure□ 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。
发货人（名称、地址）
：
Shipper ( name,address ) ：
承运人名称（或其代理人）：
Carrier ( or its agent) ：
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
船名和航次 ：
Ship’s name & Voyage NO. :
装卸港：
Port of Loading:
卸货港：
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℃/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; Vapour Pressure; Solubility in Water; Viscosity; Acidity; TLV(ppm);LC 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：
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:
主 管 机 关 签 注 栏 ：
Remarks by the Administration: 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 :
This declaration should be made in tripartite, one is kept by the Administration for file, and two for the declarer and the ship respectively.
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：
航
次：
进港
始发港:
抵港时间：
Ship’s 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:
Time of Loading:
货物正确运输名称 Proper Shipping Name of
the Goods 类别/性质 Class/Property 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，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 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 complete 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.
船舶载运污染危害性货物申报单 Declaration Form For Hazardous
Goods
Carried By Ships （散装液体物质）
（Bulk Liquids）
船
名：
国
籍：
进港
始发港:
抵港时间：
Ship’s 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 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: 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（M 3 ）
disposal of tank washing water/ water containing harmful substances/mixtures into port reception facilities, estimated quantity
tons (M 3 )
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 ship’s certificates concerning safe transportation and pollution Prevention are all valid and complete; the ship’s construction, 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. 附送以下单证、资料：
The following document(s) and information are submitted in addition: 船长/申报人员：
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：
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 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.
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