SampleIMDGShippingformMixedLoad.doc
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MULTIMODAL DANGEROUS GOODS FORM
This form maybe used as a dangerous good declaration as it meets the requirements of SOLAS 74, chapter regulation 4; MAROL 73/78, Annex III, regulation 4.
1. Shipper/ Consignor/ Sender
2. Transport document number: 10089
Bavarian Chemical Works
379 Plockstrasse st.
Dusseldorf, Deuchland
6. Consignee
New Clear Chemical Co.
3500 Chesapeake parkway
Cherry Hill, New Jersey 08034
3. Page 1 of 1 pages
Shipper’s Reference no.: 25200250589
5. Freight Forwarder’s Reference:
7. Carrier (to be completed by carrier):
SHIPPERS DECLARATION
I hereby declare that the contents of this consignment are fully and accurately described below by the Proper Shipping Name, and are classified, packaged, marked and labeled/ placecard and are in all respects in proper condition for transport according to the applicable international and national governments.
9. Additional Handling Information
8. This shipment is within limitations prescribed for
(Delete non-applicable)
CARGO AIRCRAFT
ONLY
PASSGENGER & CARGO
AIRCRAFT
Emergency Contact 1-800-651-1234 Pro Chem USA
10. Vessel/flight no and date
OOCL Singapore
11. Port/ Place of discharge
Elizabeth, NJ
11. Port/ Place of Loading
Rotterdam, Holland
12. Destination
Cherry Hill, NJ
DANGEROUS GOODS
• You must specify: Proper Shipping Name, hazard class, UN No. packing group, (where assigned) marine pollutant and observe the mandatory requirements under applicable national and international governmental regulations. For the purpose of the IMDG Code, see 5.4.1.4
• For the purpose of the IMDG see 5.4.2
Signature of Declarant Rilka Fokkner
Signature of Driver
Signature of Declarant Pieter Dressler
Place and date: Dusseldorf, Deuchland 17/02/04
Name/Status of Delcarant:
Pieter Dressler/ Service Manager
22. Name of company (shipper preparing this note)
Bavarian Chemical Works
Place and date: Rotterdam, Holland 17/02/04
Name/Status of Delclarant:
Rilka Fokkner/ Supervisor
20. Name of company
Weiss Furden Forwarding Inc.
CONTAINER VEHICLE PACKING CERTIFICATE
I hereby declare that the goods described above have been packaged/ loaded into the container/ vehicle identified above in accordance with the applicable provisions
MUST BE COMPLETED AND SIGNED FOR ALL CONTAINER/VEHICLE LOADS BY PERSON RESPONSIBLE FOR PACKING/ LOADING
Container identification No. /
Vehicle registration No.
: OOLU352594
16. Seal Number (s)
: B10078
17. Container vehicle size and type
: 20GP
18. Tare mass (kg)
: 6600 kg
19. Total gross including tare (kg)
: 14324 kg
Hauler’s Name: Timothy Trucking Inc.
Vehicle registration No.: 12698
Signature and date
21. RECEIIVING ORGANIZATION RECEIPT
Received the above number of packages/ container/ trailers in apparent good order and
Condition, unless state hereon: RECEIVING ORGANIZATION REMARKS
14. Shipping marks *Number and kind of packages, description of goods Gross mass (kg) Net mass (kg) Cube (m²)
20 drums 179k UN1779, FORMIC ACID, class 8, II EmS F-A S-B 3400 kg
22 drums UN1846, Carbon Tetrachloride, 6.1, II, RQ 3960 kg
MARINE POLLUTANT EmS F-A, S-A
8 drums Ink (non regulated) 364 kg
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