船 舶 载 运 危 险 货 物 申 报 单(液体)

船 舶 载 运 危 险 货 物 申 报 单

Declaration Form for Dangerous Goods Carried By Ships

（散装液体货物）

船 名: Ship’s name: 国 籍: Nationality: 进港 始发港:

Port of Departure: 抵港时间:

Time of Arrival: 所有人: 航 次: 出港 作业泊位:

装货时间:

本轮液舱中存有下述压载水/污水：

The ballast / bilge water remained in tanks on board: 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） tank washing (water wash) □是 / □否 Yes No

2. 使用清洁剂/添加剂洗舱 tank washing by detergent / additives □是 / □否

Yes No 3. 原油洗舱 crude oil washing □是 / □否 Yes No 4. 驱气作业 gas freeing □是 / □否

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 3此申报单一式三份，经批准后，一份留海事管理机构存查，一份退申报船舶留持，一份分送港口管理机构。 This declaration should be made in tripartite, one is kept by the Maritime Safety Administration for file, one for the declarer and one for port authority.

中华人民共和国海事局监制