KONTRAKTOR - PERTAMBANGAN - PEMASARAN BATUBARA

Jalan Dr. Sutomo No. 50 RT. 14 Kota Balikpapan - Kalimantan Timur 76124
Email : brianutama.corp@gmail.com

DANGEROUS GOODS DECLARATION

Shipper ( Pengirim ) Reference Number ( Nomor Referensi )
CV. BRIAN UTAMA
Samboja Kutai Kartanegara
Emergency Call :

Consignee ( Penerima Barang ) Carrier ( Pengangkut )

PT.BORNAVA INDOBARA MANDIRI KM. PRATIWI RAYA VOY 31

Container packing certificate / vehicle declaration Name , company / organization of signature

( Sertifikat packing ) ( Nama , perusahaan / organisasi )
Declaration ( Pernyataan ) CV. BRIAN UTAMA
It is declared that the packing of the container / vehicle Place and date ( Tempat & tanggal )
has been out in accordance whit the general introduction Samboja 25/10/2023
IMDG Code
( telah dinyatakan bahwa kemasan didalam container sudah Signature on behalf of packer ( Tanda tangan dan yang melakukan packing )
sesui dengan ketentuan umum IMDG Code )
To be completed for shipments in containers of vehicles
( muatan dalam container harus melampirkan sertifikat )

Ship’s name and voyage No. ( nama kapal dan voyage ) Port of loading ( Pelabuhan muat )
PELABUHAN PT. KALTIM KARIANGAU TERMINAL - BALIKPAPAN

Port of discharge ( Pelabuhan bongkar ) ( Reserved for text, intruction or other matter )
PELABUHAN TANJUNG PERAK - SURABAYA

Marks & Nos Number and kind of packages, proper shipping name IMDG Gross Goods delivered as
(if aplicable) Class/division, UN number, packaging group (where assinged)** Mass
Identification Flashpoint (in ° C)**, control and emergency temperatures** (berat) ( ) Break buk cargo
Or Identification of the goods as marine pollutant** EmS No** and kg ( ) Untized cargo
registration MFAG table No** ( jumlah & jenis packing, nama barang, klas, ( ) Buk packages
number(s) of nomor UN, group packing, titik nyala, temperature darurat,
The unit identifikasi pencemaran laut, nomor EMS, nomor Tabel MFAG )
220.000 kg Type of unit
PARTY : ( 11 X 20 ) (container, trailer, tank,
Vehicle etc)
NO OF PCGS : 11 ( ) open
IMDG CODE : coal KGS ( ) close
UN NUMBER : 3088
CLASS : 4

**if required
Additional Information ( informasi tambahan )

Declaration ( Pernyataan ) Name, company / organization of signatory ( nama

I here by declare that the contents of this consigment are fully Perusahaan / organisasi
and accurately described above by the proper shipping name(s) CV. BRIAN UTAMA
and are classified, packaged, marked ang labeled/placarded
and are al respects in proper condition for trasnport according Date & place ( tanggal & tempat )
to the aplicable International and Nasional govermental Samboja 25/10/2023
regulation ( dengan ini saya menyatakan bahwa isi dari container yang
sebenarnya , diklasifikasikan, dikemasdan ditandai dengan kondisi yang Sign ( tanda tangan & cap )
memadai untuk dikirim, sesuai dengan peraturan Internasional dan Nasional
yang berlaku )

Budi Setijahadi
Direktur

This form meets the requirement of SOLAS 74 chapter VII regulation 5 MARPOL 73/78 annex III regulation 4