Multimodal Dangerous Goods Form

This form may be used as dangerous goods declarations as it meets the requirements of SOLAS 74, chapter VII, regulation 5;
MARPOL 73/78, Annex III, regulation 4.
1 Shipper / Consignor / Sender 2 Transport document number
ChampionX Gulf Limites
PO BOX:17063-JEBEL ALI 3 Page of Pages 4 Shipper’s reference
DUBAI,UAE
5 Freight forwarder’s reference

6 Consignee 7 Carrier (to be completed by the carrier)

KEMA LOGISTICS LTD.
SHIPPER’S DECLARATION
23B TSKNETI HIGHWAY, 0162 TBILISI I hereby declare that the contents of this consignment are fully and accurately described below by
EMAIL : TAXID:405234205 the Proper Shipping Name, and are classified, packaged, marked and 1abeled / placarded and are in
OPERATIONS@KEMA.GE,GOGA@KEMA.GE all respects in proper condition for transport according to the applicable international and national
government regulations.

10 Vessel and Voyage nº 11 Port of Loading 9 Additional handling information

CMA CGM CONGO JEBEL ALI
12 Port of Discharge 13 Destination
POTI TURKMENISTAN
14 Shipping marks * Number and kind of packages; description of the goods Gross mass Net mass (kg) Cube (m3)

UN : 3265
Proper Shipping Name: CORROSIVE LIQUID, ACIDIC, ORGANIC, N.O.S. (Phosphonic Acid)
Technical Name: SCAL16640A
Class/(Subsidiary Risk) : 8
PG: 111
Flashpoint : > 100 °C
Marine Pollutant: NO

Outer Packaging : IBCS (16 )

Inner Packaging : 32 Plastic IBS with Non-Removable Head packed in 32 pallets
Gross Weight : 19,136 KGS
Net Weight : 18,224 KGS

Concentration :
Temp. Transport/Control/Emergency :
Tank Last Inspection Date :
Approved Packaging :
Net Explosive Mass :
Volume:
Special Requirement:
EMS : F-A , S-B
Emergency Response Number :+9715578498909
15 Container identification No 16 Seal numbers(s) 17 Container size & type 18 Tare mass (kg) 19 Total gross (including tare)
CMAU0296920 L4583806 20’STD (kg)

CONTAINER PACKING CERTIFICATE 21 RECEIVING ORGANIZATION RECEIPT

I hereby declare that the goods described above have been Received the above number of packages/containers/trailers in apparent good order and
packed/loaded into the container identified above in accordance with condition, unless stated hereon: RECEIVING ORGANISATION REMARKS:
applicable provisions. **
MUST BE COMPLETED AND SIGNED FOR ALL CONTAINER LOADS BY
PERSON RESPONSIBLE FOR PACKING/LOADING

20 Name of company Haulier’s name 22 Name of company (OF SHIPPER PREPARING THIS
MSCS GULF SHIPPING LLC NOTE)
Name of declarant Vehicle reg. No. Name of declarant
Mr. Kumar Mr. Kumar
Place and date Signature and date Place and date
DUBAI - 19.10.2023 DUBAI - 19.10.2023
Signature of declarant DRIVER’S SIGNATURE Signature of declarant

* 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 purposes of the IMDG Code see
5.4.1.1..
** For the purposes of the IMDG Code, see 5.4.2.