Vessel Material Removal Report

per HPD-10005 Rev. B

This form is to comply with Customs requirements for unlading ALL items from the vessels.
Shipping Request Form must be completed for domestic shipments.

Date: 2 / 9 / 10 Prepared by: LMA Ext. 2103 Fax N/A

Vessel (check one): ACS: LP:
Check One: BCSC BMM DBTM Energia Semco Sea Launch Yuzhmash
Other (please specify)      
Model No: Serial No: Description Used On / Next Higher Qty Weight lb/kg Value(U.S.$)
BW Gas See Descr Personal gas measure eqpt LP 3 1 $1,500.00
            SER# KA208-030481                       
            SER# KA208-030461                       
            SER# KA208-030566                       
                                        
                                        
            Attach additional sheets if needed                       
Total no. cartons/boxes
* Hazardous Material: Yes No removed / 1 TOTALS: > 1 45 kg $500.00
shipping: >>
PART 1 - Reason for Removal – All partners must complete this part
Was Item on-board ACS or LP initial arrival in 1998 from Russia: Yes No Country of Origin/Mfg: USA
Was Item purchased and laden aboard while in the U.S. and after initial arrival: Yes No Approx. Date: 2007
Note: Above 2 questions must be answered accurately and declared to the best of your knowledge to satisfy U.S. Customs regulations.
1. Storage – Estimated number of days       Details:      
2. Disposal Details:      
3. Repair – Home Port Offsite Where: Wilmington Inst Details: 310-834-1133
4. Remove from Homeport Details:      
5. Other (provide details)      
PART 2 - Offsite Vessel Spares Repair / International Shipping & Delivery Information
Only BMM, CIS or parties shipping international need to complete this part
Company Attention Phone No. Fax No. Email Address
Wilmington Inst.       (310) 834-1133 (   )            
Street Address City State Zip Code Country
332 N. Fries Avenue Wilmington CA 90744 USA
1. Unit WILL WILL NOT return to Home Port. (Check One)
2. Mode of Shipment: Domestic Vendor pickup Delivery Date
Requested International Air Surface
3.      W.O. Authorization
4. Other repair or shipping details:      
5. Special Packing, Handling, or Storage Instructions: None
Hardware transferred by: Hardware released to: Company:      
Signed by:       Date:    /    /
   Signed by:       Date:    /    /   
For Logistics Use Only For Import / Export Use Only
Removal Date: Control No:
Location:      File No.:      
Name: Signature: Disposition:
     
           
Date Sent to I/E Dept.: Approved by: Date: Ext:
   /    /            /  /        
Remarks: Cc to: SL Export
      Shipping/Receiving B-13 Logistics Rev 04/02

FormHPD-10005 Revision B