关于执行《国际海运固体散装货物规则》有关事项的通知

国   籍：

Nationality:                  

经 营 人：

Manager:                

□出港

Departure

作业泊位：

Berth:                       

作业时间：

Time of Loading:                

兹声明根据船舶装载固体散装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。申报内容准确无误。

I hereby declare that, in accordance with the   provisions of the safe transportation of solid bulk cargoes by ships and   pollution prevention, this 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.

主 管 机 关 签 证 栏

Remarks by the Administration

轮船长/申报员:

Master / Declarator:               

船长/申报员证书编号:

Certificate No.:                   

船舶/代理人（盖章）

Ship / Agent (Seal)

日期:

Date:

紧急联系人姓名、电话、传真、电子邮箱：

Emergency Contact Person’s Name, Telephone No.,   Fax, and E-mail:

托运人

(Shipper)

运输单证编号

(Transport   document Number)

收货人(Consignee)

承运人(Carrier)

运输工具的名称/方式

(Name/means   of transport)

出发港口/地点

(Port/place   of departure)

指南或其他事项

(Instructions   or other matters)

目的港口/地点

(Port/place   of destination)

货物的一般性描述

（货物种类/颗粒尺寸）

General   description of the cargo

(Type   of material/particle size)

总重（千克/吨）

Gross   mass (kg/tonnes)

如适用，散装货物的特殊说明(Specifications of bulk cargo, if applicable:)：

积载因数(Stowage factor)：

如适用，静止角(Angle of repose, if applicable)：

平舱程序(Trimming procedures)：

如有潜在危险性，其化学特性(Chemical properties if potential hazard*)：*

*例如：类别和联合国编号或仅在散装运输时具有化学危险的物质(* e.g., Class & UN No. or “MHB”)

货物组别(Group of the cargo)

□  A和B组*( Group A & B*)

□  A组*(   Group A*)

□  B组(Group   B)

□  C组(Group   C)

*   易流态化货物（A组和A及B组货物）

*   For cargoes which may liquefy (Group A and Group A and B cargoes)

适运水份极限

(Transportable   Moisture Limit)

运输时的水份含量

(Moisture   content at shipment)

货物相关特殊性质

（例如可快速溶于水）

Relevant   special properties of the cargo

(e.g.,   highly soluble in water)

额外证书*Additional certificate(s)*

□  水份含量和适运水份极限证书Certificate of moisture content and transportable   moisture limit

□  风化证书(Weathering   certificate)

□  免除证书(Exemption   certificate)

□  其它（需说明）Other   (specify)

*如需要(* If    required)

声  明(DECLARATION)

兹声明：托运货物已完全并准确地予以说明。据我所知并相信所给出的试验结果和其它说明准确无误，可被视为拟装货物的代表。

(I   hereby declare that the consignment is fully and accurately described and   that the given test results and other specifications are correct to the best   of my knowledge and belief and can be considered as representative for the   cargo to be loaded.)

签字人姓名/身份，公司/组织名称

Name/status,   company/organization of signatory

地点和日期

Place   and date

代表托运人签字

Signature   on behalf of shipper