MARITIME DECLARATION OF HEALTH

Port of : SP PORT TARAHAN - INDONESIA

Name of ship : M/V BJS 1
IMO No: 9665451
Arrived from Port: SIPPORTTELUKBAYUR - INDONESIA; Sailing to: SIPPORTTARAHAN - INDONESIA
Nationality: INDONESIA
Gross Tonnage: 6186 T ; Net Tonnage :3055 T
Name of Master : AGUSMAWAN SUPRIATUN
Valid sanitation control exemption cert. carried on board: Yes
Issued Date : 26-10-2021
Expiry Date : 26-04-2022
Passengers : NIL
Number of crew : 19 CREWS
List of ports of call with date of departure :

N0 PORT ARRIVAL DATE DEPARTURE DATE SECURITY LEVEL

1. TUBAN 29-April-2022 08-Mei-2022 1

1
2. DUMAI 20-April-2022 25-April-2022 1
1
3. TUBAN 03-April-2022 16-April-2022 1
1
4. TARAHAN 22-Maret 2022 01-April 2022 1
2
5. 3 TUBAN 17-Maret 2022 20-Maret 2022 1

6. 4 TARAHAN 04-Maret-2022 15-Maret-2022 1

7. 5 TUBAN 26-Maret-2022 01-Maret-2022 1

8. 6 TARAHAN 21- Feb-2022 25- Feb-2022 1

9. 7 TUBAN 16- Feb-2022 20- Feb-2022 1

10. TARAHAN 09-Feb-2022 14-Feb-2022 1

Answer
Health questions
Yes ()
or no
Has any person died on board during voyage?
NO
Is there on board or has there been during the international voyage any case of
NO
disease
which you suspect to be infectious nature?
Has the total number of ill passengers during the voyage ?
4.Is there any ill person on board now? N
Was a medical practitioner consulted? O
are you aware of any condition on board which may lead to infection or spread of N
disease? O
Has any sanitary measure….been applied on board? 8.Have any stowaway on N
board? O
9.Is there a sick animal or pet on board? N
I hereby declare that the particular and answers to the question give in this O
declaration of health (including the schedule) are true and correct to the best of
my knowledge and belief.
N
O
N
O
N
TARAHAN, 28 JUNI 2022
O
MASTER