Multimodal Dangerous Goods Form ‘This form may be used as a dangerous goods deciaration as it meets the requirements of Solas 74, chapter Vl, regulation 6; MARPOL 73/78, Annex Il, regulation 4 B Transport Document Number, PNQHO1620900 — [Freight Forwarders relerenes [' Shipper/Consignor’Sender ‘Shublam Pharmachem Pvt Ltd | 205-206, Laxmi Piaza, Laxmi Industrial Estate, Link Road, Andheri West, Mumbai - 400053, India 6 Consignee [SHIPPER'S DECLARATION hereby declare that he contents ofthis consignment are fuly and securely descrbed below by the proper shipping name, and are lassi, Packaged, marked and labeled placard and are in all respects n proper ‘anaition far tranepoct according to the appicable international and national fi2 Port of decharge [1S Destination EMA SEAPORT, GHANA |TEMA SEAPORT, GHANA 24 X7 EMERGENCY CONTACT PERSON NAME : SACHIN [14 Shipping Marks "Number and kind of packages, description of goods Gross: Net | Total No, Weight weight | Of Packages 154.190 1000,000] 40 DRUMS} Kas. KGS. Received the above numberof packagesiconainersillers in apparent od order and condtion, unless stated Hereon: RECEIVING JORGANIZATION RE-MARKS: blacedtoaded Into ie contanerivenicle identified above In ccordane with te applicable provisions. “MUST BE. SOMPLETED AND SIGNED FOR ALL. CONTAINERVEHICLE [LOADS BY PERSON RESPONSIBLE FOR PACKINGILOADING [20 Name of company : SHUBHAM PHAMACHEM PVT, pace ‘Name of company ES ae Foomied saat eamaa deat Ren SAGE Ltcharancne Place and date fama [Place and date Oy ria cata Pan ttaane Zo Le re [DRIVER'S Teo b= ERNETS,. Prmurect eco ea