_Toc14925
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□
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℃/℃） ；水中溶解度；粘度；酸度；TLV （ppm），LC50；LC50(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);LC50；LD50(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、其他应急措施）：
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 :
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.
