| MULTIMODAL DANGEROUS GOODS FORM | ||||||||||
| This form meets the requirements of SOLAS 74, Chapter VII, regulation 5; MARPOL 79/78, Annex III, regulation 4. | ||||||||||
| 1 Shipper/Consignor/Sender | 2 Transport document number | |||||||||
| 3 Page 1 of 1 | 4 Shipper's reference | |||||||||
| 5 Freight forwarder's reference | ||||||||||
| 6 Consignee | 7 Carrier | |||||||||
| #N/A | ||||||||||
| #N/A | ||||||||||
| #N/A | SHIPPERS DECLARATION | |||||||||
| #N/A | I hereby declare that the contents of this consignment are fully and accurately described | |||||||||
| #N/A | below by the Proper shipping Name, and are classified, packaged, marked and labeled/placarded | |||||||||
| and are in all respects in proper condition for transport according to the applicable | ||||||||||
| international and national government regulations. | ||||||||||
| 8 This shipment is within the limitations prescribed for: | 9 Addidional handling information | |||||||||
| (Non-applicable is deleted) | Emergency +32-35755555 | |||||||||
| 10 Vessel/flight No. And date | 11 Port/place of loading | (ref. ECLN/08/00495 | ||||||||
| SGS EWACS NV | ||||||||||
| 12 Port/place of discharge | 13 Destination | Keetberglaan 4-Haven 1091 | ||||||||
| #N/A | B-9120 Melsele | |||||||||
| #N/A | ||||||||||
| 14 Shipping Marks | Number and kind of packages; description of goods *) | Gross mass (kg) | Net mass (kg) | |||||||
| #N/A | #N/A | #N/A | ||||||||
| #N/A | ||||||||||
| #N/A | ||||||||||
| 15 Vehicle registration No. | 16 Seal number | 17 Container/vehicle & type | 18 Gross weight (kg) | 19 Net weight (kg) | ||||||
| #N/A | #N/A | |||||||||
| CONTAINER / VEHICLEPACKING CERTIFICATE | 21 RECEIVING ORGANISATION RECEIPT | |||||||||
| I hereby declare that the goods described above have been | Received the above number of packages/containers/trailers in apparant good order and | |||||||||
| packed/loaded into the container/vehicle identified above in | condition, unless stated hereon: RECEIVING ORGANISATION REMARKS: | |||||||||
| accordance with the applicable provisions. **) | ||||||||||
| MUST BE COMPLETED AND SIGNED FOR ALL | ||||||||||
| CONTAINER/VEHICLE LOADS BY PERSON | ||||||||||
| RESPONSIBLE FOR PACKAGING/LOADING | ||||||||||
| 20 Name of the company | Haulier's name | 22 Name of company (OF SHIPPER | ||||||||
| PREPARING THIS NOTE) | ||||||||||
| Name/status of declarant | Vehicle registration No. | Name/status of declarant | ||||||||
| Place and date | Signature and date | Place and date | ||||||||
| 05/05/2017 | 05/05/2017 | |||||||||
| Signature of declarant | DRIVER'S SIGNATURE | Signature of declarant | ||||||||
| i.o. | ||||||||||
| *) DANGEROUS GOODS: You must specify: Proper Shipping Name, hazard class, UN No., packing group and flashpoint, (where assigned) | ||||||||||
| marine pollutant and observe the mandatory requirements under applicable national and international government regulations. For | ||||||||||
| the purposes of the IMDG Code see 5.4.1.1 | ||||||||||
| **)For the purposes of the IMDG Code see 5.4.2 | ||||||||||