Certificate of Fitness for Ship Carrying Dangerous Goods

2011.01.01

APPLICATION FOR SURVEY AND ISSUE

OF

“CERTIFICATE OF FITNESS FOR SHIP CARRYING DANGEROUS GOODS”

To : NIPPON KAIJI KYOKAI Date:

We hereby request you to carry out the survey and to issue the “Certificate of Fitness for Ship Carrying Dangerous Goods” in accordance with Reg.54 / Reg.54 with 96 amend / Reg.19*, Chapter II-2, SOLAS 1974, as mentioned below.

Ship’s Name (or Hull No.) / Class No.
Ship Type / (tick in box) See Note (1)
□ Container Carrier / □  Ro-Ro Ship
□  / □ Others( )
Flag : / Official No. :
Shipowner : / Gross Tons :
I. □ Carriage of dangerous goods in packaged form (tick in box)
Cargo spaces to be certified for the stowage of dangerous goods in packaged form
□ Weather deck □ Cargo Holds (Hold No. ) □ Others ( )
Classes of dangerous goods intended to be carried in packaged form (tick in boxes)
□ Class 1 (Explosives)
□ Class 2 (Gases: compressed, liquefied or dissolved under pressure)
(□ flammable □ non-flammable)
□ Class 3 (Flammable liquids)
□ Class 4.1 (Flammable solids)
□ Class 4.2 (Substances liable to spontaneous combustion) / □ Class 4.3 (Substances which, in contact with water, emit flammable gases)
(□ liquid □ solid)
□ Class 5.1 (Oxidizing substances)
□ Class 5.2 (Organic peroxides)
□ Class 6.1 (Toxic substances)
□ Class 8 (Corrosive substances)
□ Class 9 (Miscellaneous dangerous substances)
II. □ Carriage of dangerous goods in solid form in bulk (tick in boxes)
Cargo spaces to be certified for the stowage of dangerous goods in bulk
□ Cargo Holds (Hold No.: ) □ Others ( )
Classes of dangerous goods intended to be carried in bulk**
□ Class 4.1 (Flammable solids)
□ Class 4.2 (Substances liable to spontaneous combustion)
□ Class 4.3 (Substances which, in contact with water, emit flammable gases) / □ Class 5.1 (Oxidizing substances)
□ Class 6.1 (Toxic substances)
□ Class 8 (Corrosive substances)
□ Class 9 (Miscellaneous dangerous substances)
□ Others (Materials:
Date/Port of Survey / Date: Port:
Local Agent: Tel Fax:
Applicant Name :
Address:
Contact Person: (Signature)
Tel: Fax:
All survey fees and expenses incurred in above survey and certification is paid by;
Name of Company:
Address:

Note (1) Under the provision of SOLAS regulation, container carrier is defined as a ship fitted with cell guides in the cargo holds for stowage of containers.

* : Delete as appropriate.
**: If no fixed fire-fighting system for cargo holds, cargoes within the Classes may be restricted according to the applicable cargo list attached to exemption certificate for the system.