港口、码头船岸检查表

船/岸安全检查表
SHIP/SHORE SAFETY CHECK LIST Ship’s Name
船名……………………………………….
Berth
泊位………………………………………Port
港口……………………………………….
Date of Arrival
抵达日期……………………………………..Time of Arrival
抵达时间……………………………………...
填表须知
INSTRUCTIONS FOR COMPLETION:
为保证安全作业，下列所有问题的答复均是肯定的,可在相应的方格内清楚地打上(√)标号。

如果不能给予肯定回答，应说明理由，而且船舶和码头之间均达成关于应采取的适当预防措施的协议。

如果认为有的问题不适用，应在备注栏里加以说明。

The safety of operations requires that all questions should be answered affirmatively by clearly ticking (√) in the appropriate box. If an affirmative answer is not available, the reason should be given and agreement reached upon appropriate precautions to be taken between the ship and the terminal. Where any question is considered to be not applicable, then a note to that effect should be inserted in the remarks column.
“船舶”和“码头”栏目下的方格，表示由负责方实施检查。

A box in the column ‘ship’ and ‘terminal’ indicates that the party concerned should carry out checks.
在“代码”栏目里的A，P或R字母，分别表示如下的意义：
The presence of the letters A, P or R in the column ‘Code’ indicates the following:
A –（协议）表示该检查项应通过协议或程序来处理，并在检查表中的“备注”栏中明确或者通过其它一些双方可接受的表格来交流这些协议和程序。

A–(‘Agreement’). This indicates that the referenced consideration should be addressed by an agreement or procedure that should be identified in t he ‘Remarks’ column of the Check List, or communicated in some other mutually acceptable form.
P—（批准）在否定回答的情况下，未经主管当局的书面许可，不可进行作业。

P–(‘Permission’). In the case of a negative answer to the statements coded ‘P’, no operations are to be conducted without the written permission from the appropriate authority.
R—（复查）表示在不超出声明同意的时间间隔须重复检查的项目。

R–(‘Re-check’).This indicates items to be re-checked at appropriate intervals, as agreed between both parties and stated in the declaration.
仅在所有方检查和接受他们分配的职责和责任后方可签署共同声明
The joint declaration should not be signed until all parties have checked and accepted their assigned responsibilities and accountabilities.
PART ‘A’ – BULK LIQUID GENERAL - PHYSICAL CHECKS A 部分－散装普通液货－现场核实
If the ship is fitted, or is required to be fitted, with an Inert Gas System (IGS) the following points should be physically checked:
如船舶安装有，或要求安装惰气系统(IGS)，下列各条应进行现场核查：
PART ‘B’ – BULK LIQUID GENERAL – VERBAL VERIFICATION B 部分－散装普通液货－口头确认
If the ship is fitted, or is required to be fitted, with an Inert Gas System (IGS) the following statements should be addressed.
如果船舶安装了，或被要求安装惰气系统(IGS)，下列各条应进行实际检查：
If the ship is fitted with a Crude Oil Washing (COW)system, and intends to crude oil washing, the following statements should be addressed.
如果船舶安装原油洗舱系统，需进行原油洗舱作业，应完成下列内容
If the ship is planning to tank clean alongside, the following statements should be addressed.如果船舶计划在靠泊期间清舱，应完成以下内容
•Delete Yes or No as appropriate 根据适用情况删去“是”或“否”
PART ‘C’ – BULK LIQUID CHEMICALS - VERBAL VERIFICATION
PART ‘D’ – BULK LIQUEFIED GASES - VERBAL VERIFICATION D 部分－散装液化气－口头确认
Tank No 1 Tank No 5 Tank No 8 Tank No 2 Tank No 6 Tank No 9 Tank No 3 Tank No 7 Tank No 10 Tank No 4
DECLARATION
声明
We, the undersigned, have checked the above items in Parts A and B, and where appropriate, Part C or D, in accordance with the instructions and have satisfied ourselves that the entries we have made are correct to the best of our knowledge.
我们, 下面签名者, 已经对本安全检查表内A/B部分的各个项目，如果适用, 包括C或D部分的项目，根据指导进行了检查，并确信就我们所了解的情况，我们所填写的内容是正确的。

We have also made arrangements to carry out repetitive checks as necessary and agreed that those items coded ‘R’ in the Check List should be re-checked at intervals not exceeding _____ hours.
我们对协议进行复查的项目也已作好安排，并同意在不超过时间间隔必须对那些“代号”栏中标有“R”的项目进行复查。

If to our knowledge the status of any item changes, we will immediately inform the other party.
如果我们获知任何项目的状态发生变化，将立即通知另一方。

Record of repetitive checks 重复检查的记录:
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