Standard Formulir Aktivitas Kapal Di Pelabuhan PDF

LAMPIRAN III
Standard Formulir Aktivitas Kapal

di Pelabuhan
1. Compartment Log Sheet
2. Delivery Certificate
3. Disch Agreement
4. Dry After Disch Certificate
5. Dry Before Loading Certificate
6. Inspection Record
7. Letter of Discrepancy
8. Letter of Protest Pumping Rate
9. Loading Agreement
10. Log Abstract
11. Master Cable
12. Master Requisition
13. Notice of Readiness
14. Notice of Sealing
15. Off Hire Certificate
16. On Hire Certificate
17. Oil Spill
18. Pumping Log
19. Redelivery Certificate
20. ROB Bunker
21. Sailing Order
22. Ship Condition
23. Statement of fact
24. Statement of Reduce rate
25. Stop Temporary
26. Tanker Time Sheet
27. Ullage Report
PT PERTAMINA (PERSERO)
SHIPPING MARKETING & TRADING DIRECTORATE
SHIPPING OPERATION DIVISION, HEAD OFFICE 19TH Floor, Jln. Merdeka Timur 1A Jakarta 10110
Phone : (62-21) 3816367, 3816314, 3816339, 3816353, 3816217. Fax : 3455430, 3816348, 3507121
E-mail: opstanker@pertaminashipping.com
COMPARTMENT LOGSHEET
AFTER/BEFORE/LOADING/DISCHARGING
VESSELS NAME
PORT / DATE
VOYAGE
CARGO
TANKS
NO
(1)
PORT
1
2
3
4
5
6
7
8
CENTER
1
2
3
4
5
6
7
8
STBD
1
2
3
4
5
6
7
8
TOTAL
:
:
:
DRAFT (Mtr)
BEFORE LOAD / DISCH
AFTER LOAD / DISCH
TANK OBSERVATION
GRADE
CORR
ULL
GROSS
VOL (KL)
(2)
(3)
(4)
LOADING MASTER
SAMPLES OBS
FREE WATER
VOL
DIP
(KL)
(5)
(6)
NET
VOL
(KL)
(7)
DENS
TEMP
(oC )
DENSITY
@ 15C
(TABLE 53)
VOL COR
FACTOR
(TABLE 54)
NET KL
@ 15C
(8)
(9)
(10)
(11)
(12)
PT. PERTAMINA (PERSERO)

Shipping Representative/Agent
VOLUME
CONV
FACTOR
(TABLE 52)
(13)
:
:
BARRELS
@60F
(14)
WEIGHT
CONV
FACTOR
(TABLE 57)
(15)
CHIEF OFFICER
LONG
TONS
METRIC
TONS
(16)
(17)
TH
SHIPPING OPERATION DIVISION, HEAD OFFICE 19 Floor, Jln. Merdeka Timur 1A Jakarta 10110
Phone : (62-21) 3816367, 3816314, 3816339, 3816353, 3816217. Fax : 3455430, 3816348, 3507121
DELIVERY CERTIFICATE
This is to certify that MT / SS / TB :

Call Sign
Flag :
Gross Tons :
was duly delivered
by the Master (for and on behalf of Owner), to and accepted :by
(for and on behalf of Charterer), at
hours local time, on
It was also agreed at that time that the vessel had onboard bunker and fresh
water as follows :
water as
Marine Fuel Oil

Marine Diesel Oil
Autogas (HSD)
Fresh Water
:
:
:
:
Metric Ton.
Metric Ton.
Metric Ton.
Ton.
Port
Date
:
:
:
Port
Representative
(For and on behalf of Charterer)
Master MT / SS / TB
(For and on behalf of Owner)

DIREKTORAT PEMASARAN DAN NIAGA - PERKAPALAN
LOADING/DISCHARGING AGREEMENT
Name of Ship
Voy No.
Date
Berth/Jetty
:..........................
:..........................
:..........................
:..........................
Disch. Port
:......................
Loading Port
:......................
Draft
F : . . . . . . . . . Mtr
M : . . . . . . . . . Mtr
A : . . . . . . . . . Mtr
RECEIVING AVAILABILITY AND CAPACITY

Shore
Ship's
Grade
Line(LA) use &
Load/Disch. Rate
KL/hrs
Pressure
kg/cm2
C O P use
Line =
inchi
Line=
inchi
Quantity Load/Disch
in KL Obs
KL/hrs 1.
kg/cm2 2.
COP
3.
Total Quantity Load/ Discharge =

Load/Disch. Rate / Pressure at Manifold as Agreement : . . . . . . . . . . . . .KL/hrs - . . . . . . . . . . .kg/cm 2
Estimated Completed Load/Disch. time
(including stripping)
.........................
Loading Master
Remark :
: . . . . . . . . . . . . . . . . . . .hrs
......................
Master
In the event the discharging rate/pressure at manifold of the vessel is below the agreement mention above
then the vessel will be claim for slow pumping, if the slow pumping is caused by the vessel fault.
...............................................................................................
...............................................................................................
...............................................................................................
Note
:
Line
: Pipa (muat / bongkar)
SFBD : Ship's Figure Beofore Discharge
F : Forward (depan)
LA
: Loading Arm (pipa muat)
Voy No.: Voyage No. (No. Pelayaran)
M : Mid (tengah)
COP
: Cargo Oil Pump (pompa utama) KL Obs : Kilo Liter Observasi (pengamatan)
A : After (belakang)
Line
: Diameter pipa dalam inchi
Shore : Darat
Hrs : Jam
Grade
: Jenis Muatan
Berth/Jetty : Nama tempat sandar (dermaga/SBM)
- Kegiatan bongkar harus direcord dalam pumping log dan ditandatangani pihak kapal dan pihak darat.
- Penurunan tekanan / rate atas permintaan darat/kapal harus dibuat secara tertulis dan ditandatangani pihak kapal &
darat
TH
Phone : (62-21) 3816367, 3816314, 3816339, 3816353, 3816217. Fax : 3455430, 3816348, 3507121
DRY CERTIFICATE
(After Discharging)
PORT:
DATE:
20
To:
I, the Loading Master, have inspected all ships tanks
at
and found dry & empty.
20
All cargo on board has been delivered in good order and condition
Remark:
Quantity of ROB
or OBQ
Yours truly,
Loading Master
To Loading Master,
We confirmed acceptance of your written dry certificate at
Yours truly,
Master
TH
Phone : (62-21) 3816367, 3816314, 3816339, 3816353, 3816217. Fax : 3455430, 3816348, 3507121
DRY CERTIFICATE
(Before Loading)
PORT:
DATE:
20
To:
I, the Master of
at
and found dry & clear.
, have inspected all ships tanks

20
And ready to commence loading of the cargo

Remark:
Quantity of ROB
or OBQ
:
:
Yours truly,
Master
To Master of MT,
We confirmed acceptance of your written dry certificate at
hours local time On
Yours truly,
Loading Master
SHIPPING OPERATION DIVISION, HEAD OFFICE 19TH Floor, Jln. Merdeka Timur 1A Jakarta 10110
Phone : (62-21) 3816367, 3816314, 3816339, 3816353, 3816217. Fax : 3455430, 3816348, 3507121
INSPECTION RECORD
BOTTOM
SHIPS COMP.
(1)
PORT
CENTER
STBD
WALL
VALVE
HEATING COILS
HEATING COILS
Empty
Free
Water
Clean
D/S/WP
Clean
D/S/WP
O/C
Sealed
Sealed
Number
D/S
Leak
Empty
Content
(2)
(3)
(4)
(5)
(6)
(7)
(8)
(9)
(10)
(11)
(12)
(13)
(14)
1
2
3
4
5
6
7
8
1
2
3
4
5
6
7
8
1
2
3
4
5
6
7
8
Cofferdam
Slop Tank
Fore Peak Tank
After Peak Tank
Notes: Oil Inspector for Cleanliness :

Loading Master
: for Cargo
Discharging Master
P&T Agent
Oil Inspector/ Loading Master

Discharging Master
Mualim I / Chief Officer
TH
Phone : (62-21) 3816367, 3816314, 3816339, 3816353, 3816217. Fax : 3455430, 3816348, 3507121
SURAT PERBEDAAN ANGKA MUATAN

LETTER OF DISCREPANCY
Tanggal
Date
Voyage
Pelabuhan
Port
Kepada
To
Dari Nakhoda
From Master
:
:
Setelah pengecekan kembali dengan teliti figures

muatan yang dimuat serta disesuaikan dengan draft
dan deadweight dari kapal kami, maka terdapat
perbedaan lebih dari setengah () persen antara B/L
figures dengan ships figures dengan perincian
sebagai berikut :
Jenis
Grade
Angka Kapal
Ship Figures
After having been rechecked the figures of the

cargo loaded carefully and compared it with the
draft and deadweight of our vessel, a difference
of more than half () percent between B/L and
the ships figures has been found as follows :
No. dan angka B/L

No. and B/L figures
Selisih
Difference
Bbls
Bbls
Bbls
Bbls
Bbls
Bbls
Berdasarkan figures tersebut diatas dengan ini kami

menyatakan bahwa B/L telah kami tandatangani
dibawah protes dengan ketentuan bahwa kapal
tidak dapat dipertanggung jawabkan atas figures
pembongkaran pada pelabuhan bongkar.
Base on above mentioned figures, we here by

declare that the B/L has been signed under
protest, notably that the ship could not be hold
responsible for the outturn figures at the
discharging port.
Catatan :
Remarks :
Tanker Ullage Report pertama dan kedua diukur

dan dihitung bersama-sama Loading Master serta
Agen dan telah diserahkan ke perwakilan/Agen
PT. PERTAMINA (PERSERO).
The first and the second Tanker Ullage Report

already measure and calculated together with
Loading Master and Agent and send to
PT. PERTAMINA (PERSERO) Representative.
Hormat kami
Yours faithfully
Nakhoda
Master
Diketahui
Known by
Representative
TH
Phone : (62-21) 3816367, 3816314, 3816339, 3816353, 3816217. Fax : 3455430, 3816348, 3507121
LETTER OF PROTEST
Slow Pumping
To
DATE
PORT
BERTH
As recorded, that my vessel is capable to loading / discharging cargo at

TONS/BBLS/M3 per hour with
line
inches connection. However, shore can only supply /receive of

TONS/BBLS/M3 per hour
line. Equivalent to
hours actual loading /discharging time.
In view of the foregoing, I Master of MT
protest the delay of
loading / discharging and on behalf of my Owners and Consignee / Charterer reserves

their right to claim you for all time losses and expenses incured, if any, and that such
claims to forthcome at an appropriate time and place my principal deemed it.
Port of
Date
Loading Master
Master / Duty Officer
TH
Phone : (62-21) 3816367, 3816314, 3816339, 3816353, 3816217. Fax : 3455430, 3816348, 3507121
LOG ABSTRACT
(The voyage should cover the period End of Sea Voyage as per Log at first Loading Port until return same position Next Loading Port, after discharging all cargo)
VESSEL NAME :
Port
VOYAGE NO :
PORT TIME :
(Loading / Discharging)
End of Sea Voyage
Begin Of Sea Voyage
Date
Time
Date
Time
Cargo Load / Disch. (Long Ton)

B/L
SFAL/SFBD
Grade
Port Time
(Hours)
Remark :
SEA PASSAGE :
From
(BOSV)
Port:
Date:
Time:
Port
(Laden / Ballast)
To
(EOSV)
Port:
Date:
Distance
(Miles)
Steaming
Time (Hours)
Av. Speed
(Knots)
MFO
Fuel & FW Consumption (MT)

MDO
HSD
Date
Time
PORT TIME :
(Loading / Discharging)
End of Sea Voyage
Begin Of Sea Voyage
Date
Time
Date
Time
Cargo Load / Disch. (Long Ton)

B/L
SFAL/SFBD
Grade
Port Time
(Hours)
St. by. Eng. (EOSV)

FWE
St. by. Eng.
FWE
Comm. Load/Disc.
Complt. Load/Disc.
St. by. Eng.
FWE
St. by. Eng.
Full Away (BOSV)
SEA PASSAGE :
From
(BOSV)
Time:
(Laden / Ballast)
To
(EOSV)
Port:
Date:
Distance
(Miles)
Steaming
Time (Hours)
Av. Speed
(Knots)
MFO
Fuel & FW Consumption (MT)

MDO
HSD
FW
Time:
Hours
Description
Heat
Tk. Clean
IGS
Date
Time
Description
Hours
Steaming in/out
Idle
Load/ Disch
Ballast/ Deballast
Cargo Heating
IGS
Total
ROB ATA
ROB ATD
REPLENISHMENT
Description
Heat
Tk. Clean
IGS
Hours
Deviation to storing and / or repair port :

Miles.
Date / Hour
Date / Hour
Hour
DO :
HSD :
FW :
Fuel & FW Counsumption (MT)

MDO
HSD
FW
MFO
Fuel & FW Counsumption (MT)

MDO
HSD
FW
Hours
State exast periods of delay caused by accident engine trouble crew heavy weather and the like :
Distance to go at time of deviation to next loading / discharging port :

Place / Point of Deviation
Returned to point of deviation or corresponding position
Actual periode of deviation : Days
Bunker and F.W. consumed during the deviation periode FO :
MFO
ROB ATA
ROB ATD
REPLENISHMENT
FW
Activity
Description
Steaming in/out
Idle
Load/ Disch
Ballast/ Deballast
Cargo Heating
IGS
Total
Time:
Remark :
Port:
Date:
Activity
St. by. Eng. (EOSV)
FWE
St. by. Eng.
FWE
Comm. Load/Disc.
Complt. Load/Disc.
St. by. Eng.
FWE
St. by. Eng.
Full Away (BOSV)
Master
Chief Engineer
TH
Phone : (62-21) 3816367, 3816314, 3816339, 3816353, 3816217. Fax : 3455430, 3816348, 3507121
RE : DEPARTURE MASTER CABLE

ROC. 1863 / OT II DATED 18 / 08 / 1999 AS TO GET A COMPLETE DEPARTURE
MESSAGE. YOU ARE REQUESTED TO ADVISE ALL DETAILS BELOW AT THE FIRST
PRIORITY FOR EACH ACTIVITY:
AA.
BB.
CC.
DD.
EE.
FF.
GG.
DD.
EE.
FF.
GG.
HH.
II.
JJ.
KK.
LL.
MM.
NN.
OO.
PP.
QQ.
RR.
SS.
TT.
UU.
VV.
WW.
XX.
YY.
THANKS FOR YOUR ATTENTION COOPERATION ACK REGARDS.
TH
Phone : (62-21) 3816367, 3816314, 3816339, 3816353, 3816217. Fax : 3455430, 3816348, 3507121
MASTERS REQUISITION
Port
Date
:
:
Dear Sir :
Please supply my vessel the as / my :
With,
MARINE FUEL OIL

Maximum viscosity redwood 1 @ 100 o F
Rate per hour for delivery
KL / MT
Seconds
MARINE DIESEL FUEL

KL / MT
GAS OIL
KL / MT
DRINGKING WATER
Tons
BOILER WATER
Tons
And charge same to my Principals namely :
I require the grades to be supplied in the following order :

And * will / * will not appoint a representative to withness and check either the opening and closing meter
readings/ calculations or if meters no available, the opening and closing tank dips/calculations only
behalf.
The ship / * there will give the final stop pumping signal.
Your very truly

Master MT :
TH
Phone : (62-21) 3816367, 3816314, 3816339, 3816353, 3816217. Fax : 3455430, 3816348, 3507121
NOTICE OF READINESS
Voy. No.
PORT
DATE
TIME TENDERED
:
:
:
To:
Dear Sir,
I hereby tender you the MT
at the date time shown above as being ready in all respect to commence the
loading/ discharging of her cargo
consisting of:
Description of cargo
Approximate amount/Bill of Lading quantity
Laytime will commence as specified in the charter party covering this voyage
ACCEPTED
Date :
Very truly yours

Hour:
By :
as Agent
Master
TH
Phone : (62-21) 3816367, 3816314, 3816339, 3816353, 3816217. Fax : 3455430, 3816348, 3507121
NOTICE OF SEALING
No :
After completing :
Loaded in tank :
cargo
Of the MV / MT :
On the
:
The following valves and tanklide were sealed by Loading
Number and name valves/tanklide sealed
Total
:
:
:
:
:
:
:
:
:
:
:
:
:
pcs
pcs
pcs
pcs
pcs
pcs
pcs
pcs
pcs
pcs
pcs
pcs
20
Scaling Acknowledge by :
Signature
Chief Engineer
Loading Master
Cc
: Consignee
Chief Officer
Pelsus
Inst. Tank
TH
Phone : (62-21) 3816367, 3816314, 3816339, 3816353, 3816217. Fax : 3455430, 3816348, 3507121
OFF HIRE CERTIFICATE

Call Sign:
DWT :
Flag :
was duly off hire by PT PERTAMINA (PERSERO)
(for and on behalf of Charterer), to and accepted by Master (for and on behalf of
owner), at
It was also agreed at that time that the vessel had onboard bunker and fresh water
as follows :
Marine Fuel Oil (180cst/380cst)*
Marine Diesel Oil
Autogas (HSD)
Marine Gas Oil (MGO)
Fresh Water
:
:
:
:
:
Metric Ton.
Metric Ton.
Metric Ton.
Metric Ton.
Ton.
*)coret yang tidak perlu
Port
Date
Master MT / SS / TB
:
:
Representative
TH
Phone : (62-21) 3816367, 3816314, 3816339, 3816353, 3816217. Fax : 3455430, 3816348, 3507121
LAPORAN PEMERIKSAAN PENCEGAHAN TUMPAHAN MINYAK DI PERAIRAN

1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
Kapal
Terminal
Pemilik Kapal
Dioperasikan oleh
Agen
Nama
Alamat
Nama Nakhoda
Tiba di
Tgl
jam
Di dermaga
Tgl
jam
Berlabuh jangkar dari jam
Tgl
sampai jam
Tgl
Jenis muatan
Apakah Oil Boom dipasang
Apakah kerangan-kerangan pipa pembuangan air ballast kotor / air got ke laut tertutup rapat sebelum
penyegelan
Apakah semua penutup lubang untuk mengukur minyak di tangki muatan (ullage cover screens) ada pada
tempatnya sebelum pemompaan dimulai
Jumlah segel yang digunakan
Jumlah dispersant yang ada di kapal
Jenis
Merk Pabrik
Tanda tangan Perwira dan Pemeriksa Darat yang melaksanakan penyegelan :
Perwira Kapal
15. Apakah saluran pembuangan air dek
kapal sudah disumbat sebelum
pompa dihidupkan
16.
17.
18.
Pemeriksa Darat
Apakah talang penadah tumpahan
minyak berada dibawah manifold
kapal

minyak untuk kapal tersedia di darat.
Slang terakhir telah terpasang

jam
tgl
20
Pembongkaran/pemuatan dimulai jam
tgl
20
Selesai pembongkaran/pemuatan jam
tgl
20
Slang terakhir dilepas
jam
tgl
20
Apakah ujung slang terakhir telah tertutup rapat waktu dimulainya pemompaan ballast diatas kapal
sebelum diturunkan ke darat
jam
tgl
20
Waktu segel dibuka untuk pengisian air ballast apakah segel-segel masih utuh sebelum dibuka
jam
tgl
20
Tanda tangan Perwira Kapal dan Pemeriksa Darat waktu membuka segel :
Perwira Kapal
19. Apakah saluran pembuangan air
dek
kapal
sudah
disumbat
sebelum pompa dihidupkan

minyak berada dibawah manifold kapal
(
)
Pemeriksa Darat
minyak untuk kapal tersedia di darat.
20.
Bilamana ada minyak terlihat diatas air disekitar kapalberikan laporan terperinci dibawah ini :
21.
Data Kapal
- DWT
- GRT
- LOA
- FLAG
:
:
:
:
:
TH
Phone : (62-21) 3816367, 3816314, 3816339, 3816353, 3816217. Fax : 3455430, 3816348, 3507121
ON HIRE CERTIFICATE
This is to certify that MT / SS/ TB :
Flag :
Call Sign:
DWT :
was duly on hire by the Master
(for and on behalf of Owner) to and accepted by PT PERTAMINA (PERSERO)
(for and on behalf of Charterer),
at
as follows :
Marine Diesel Oil
Autogas (HSD)
Fresh Water
:
:
:
:
:
Metric Ton.
Metric Ton.
Metric Ton.
Metric Ton.
Ton.
*)coret yang tidak perlu
Port
Date
Representative
:
:
Master MT / SS / TB
TH
Phone : (62-21) 3816367, 3816314, 3816339, 3816353, 3816217. Fax : 3455430, 3816348, 3507121
ON HIRE CERTIFICATE
This is to certify that MT / TT/ TB :
Flag :
Call Sign:
DWT :
was duly on hire by the Master
(for and on behalf of Owner) to and accepted by PT PERTAMINA (PERSERO)
(for and on behalf of Charterer),
at
as follows :
Marine Fuel Oil
Marine Diesel Oil
Autogas (HSD)
Fresh Water
:
:
:
:
Metric Ton.
Metric Ton.
Metric Ton.
Ton.
Port
Date
Representative
:
:
Master MT / TT / TB
SHIPPING - MARKETING & TRADING DIRECTORATE
SHIPPING OPERATION DIVISION, PT PERTAMINA (PERSERO) HEAD OFFICE 11 TH Floor, Jln. Merdeka Timur 1A Jakarta 10110
Phone : (62-21) 3816367, 3816314, 3816369, 3816353, 3816217. Fax : 3455430, 3816348, 3507121
PUMPING / DISCHARGE LOG

MT
PORT OF
DATE
AVERAGE PRESS MAINTAINED SHIP RAIL
:
:
kg/m2
kg/m2
NO OF PUMP
NORMAL SERV. RPM
NO OF HOSE
SHORE LINES NO
:
:
inches
inches
DATE
NO
HOURS
PRESS ALLOW BY SHORE ON HOSE
MAIN PUMP NO.1

PRESS PUMPING
AT RAIL
RATE
RPM
(kg/cm2)
(m3/h)
CARGO GRADE AND

QUANTITY
SG/
DENSITY
MAIN PUMP NO.2

PRESS
PUMPING
AT RAIL
RATE
RPM
(kg/cm2)
(m3/h)
TEMP OBSERVED
(oC)
MAIN PUMP NO.3

PRESS PUMPING
AT RAIL
RATE
RPM
(kg/cm2)
(m3/h)
:
:
SIZE
SIZE
MAIN PUMP NO.4

PRESS PUMPING
AT RAIL
RATE
RPM
(kg/cm2)
(m3/h)
COMMENCED DISCHARGE
COMPLETED DISCHARGE
DATE
DATE
HOUR
MINUTE
HOUR
MINUTE
REMARKS
DISCH.
TIME
2
3
TOTAL
STOP
STOP DISCHARGE
FROM
TO
5
6
7
PRESSURE RECORDED SHIP' RAIL / UPPER PUMP ROOM / LOWER PUMP ROOM :
IF ANY PUMP WAS NOT IN OPERATION ADVISE REASON :
IF DISCHARGEING INTERUPTED ADVISE REASON :
IF NORMAL RPM WERE NOT MAINTAINED ADVISE REASON :
IF ANY DELAY INCURRED DUE TO SHORE ORDER ATTACH WRITTEN INSTRUCTION :
Representative
CHIEF OFFICER
MASTER
REASON
TH
Phone : (62-21) 3816367, 3816314, 3816339, 3816353, 3816217. Fax : 3455430, 3816348, 3507121
REDELIVERY CERTIFICATE
Flag :
DWT :
Call Sign :
was duly redelivered by
(for and on behalf of Charterer), to and accepted by Master (for and on behalf
Owner), at
of
It was also agreed at that time that the vessel had onboard bunker and fresh
water as follows :
Marine Diesel Oil
Autogas (HSD)
:
:
:
Metric Ton.
Metric Ton.
Metric Ton.

Fresh Water
:
:
Metric Ton.
Ton.
*) coret yang tidak perlu
Port
Date
:
:
Master MT / SS / TB
Representative
TH
Phone : (62-21) 3816367, 3816314, 3816339, 3816353, 3816217. Fax : 3455430, 3816348, 3507121
BUNKER REMAIN ON BOARD

ATA / ATD
VESSELS NAME
VOYAGE
DATE
PORT
DRAFT
Mtr
Mtr
Mtr
MFO / IFO TANKS :

NO TANK
ULLAGE /
SOUNDING
VOLUME
(KL / M3 )
TEMP
o
( C)
SG
TANKS
VCF
METRIC
TON
VOLUME
(KL / M3 )
TEMP
o
( C)
SG
TANKS
VCF
METRIC
TON
TOTAL
MDO / HSD / MGO TANKS :
NO TANK
ULLAGE /
SOUNDING
TOTAL
All bunker tanks has been inspected and calculated together between :
Representative
Note :
Average for SG MFO = 0.921 ; MDO = 0.856 ; HSD = 0.838

(ref. kpts no.074/C0000/96B1 dated April 22, 1996)
Chief Engineer :
TH
Phone : (62-21) 3816367, 3816314, 3816339, 3816353, 3816217. Fax : 3455430, 3816348, 3507121
SAILING ORDER
To : Master MT/TT/TB
Dear sir,
Please proceed to
on
of Loading/Discharging at
Cargo
Date
No
after completion
, for Loading/Discharging as follows :
Quantities :
Destination
The complete information about next port will sent via telex if necessary.
Please follow the instruction from Tanker Operation.
Yours truly
PT PERTAMINA (PERSER0)
Representative
TH
Phone : (62-21) 3816367, 3816314, 3816339, 3816353, 3816217. Fax : 3455430, 3816348, 3507121
SHIP CONDITION
MT
LAST PORT CONDITION FROM :
ARRIVAL :
REPLENISHMENT
DEPARTURE TO:
DATE
TIME
DATE
TIME
DATE
TIME
:
:
DATE
TIME
:
:
MFO
MDO
HSD
:
:
:
MFO
MDO
HSD
:
:
:
:
:
:
:
BUNKER
BUNKER
MFO :
MDO :
HSD :
MT
MT
MT
MFO :
MDO :
HSD :
FRESH WATER
BW
FW
FRESH WATER
:
:
Tons
Tons
BW :
FW :
BW
FW
:
:
Mtr FORE
Mtr AFTER
N /Miles
MT
MT
MT
FRESH WATER
Tons
Tons
BW
FW
:
:
Tons
Tons
DRAFT
:
:
:
PORT
PELABUHAN
DATE
TANGGAL
BUNKER
MT
MT
MT
FRESH WATER
Tons
Tons
DRAFT
Fore
After
Total
Distance
BUNKER
MT
MT
MT
DRAFT
Mtr
Mtr
Fore
After
:
:
Master / Chief Officer
:
( .. )
Mtr
Mtr
TH
Phone : (62-21) 3816367, 3816314, 3816339, 3816353, 3816217. Fax : 3455430, 3816348, 3507121
Statement Of Fact
(Ship Unreadiness and Readiness)
To whom it may concern
I the Master of MT/SS/TB.
Flag :
Declare that vessel is not ready on the date :
(hours local time)
In the position
ROB for
Remarks
MFO (180cst/380cst)
MDO
HSD
MGO
FW
Remarks
DWT :
hour :
while
:
:
:
:
:
MT.
MT.
MT.
MT.
Ton.
Vessel is ready for :

Date :
ROB for
Call sign :
Hour
(hours local time)
MFO (180cst/380cst)
MT.
MDO
MT.
HSD
MT.
MGO
MT.
FW
Ton.
Port :
Date :
Acknowledge
Representative
Master MT /SS/ TB :
TH
Phone : (62-21) 3816367, 3816314, 3816339, 3816353, 3816217. Fax : 3455430, 3816348, 3507121
Statement of Reduce Rate

of Loading / Discharging
I, Master MT
stated that, today,
date
at
at port
hours local time, as requested by The Loading Master,
,to temporary reduce discharging/ loading rate of cargo
from
M3 / sec
M3 / sec
to
from
hours local time,
until
hours local time.
due to :
Kindly sign and return the copy of this letter of acknowledgement.
Loading Master
Port of
Date
TH
Phone : (62-21) 3816367, 3816314, 3816339, 3816353, 3816217. Fax : 3455430, 3816348, 3507121
Statement of Temporary Stop

for Loading / Discharging

I, Master MT
stated that,
today ,
date
In port
at
hours local time, as requested by
the Loading Master,Mr.
,to temporary stop
discharging/ loading cargo from
hours local time,
until
hours local time.
due to :
Kindly sign and return the copy of this letter of acknowledgement.
Loading Master
Port of
Date
:
...
TH
Phone : (62-21) 3816367, 3816314, 3816339, 3816353, 3816217. Fax : 3455430, 3816348, 3507121
TANKER TIME SHEET

Vessel Name
Flag
Master
GRT
DWT
:
:
:
:
:
Port of
Date
Voy No.
Last Port
B/L No.
STATEMENT OF ACTIVITY
DATE
Actual Time Arrived

Anchor at Outer Bar
Pilot On Board
Anchor Up
Anchor at Inner Anchorage
Free Pratique Granted
Pilot On Board
Anchor Up
NOR Tendered
NOR Accepted
First Line to Shore
All Made Fasted
Cargo Hose Connected
Commenced Ballast / Deballast
Completed Ballast / Deballast
Commenced Load / Disch (1)
Stopped Load / Disch order by Ship / Shore
Resume Load / Disch (2)
Stopped Load / Disch order by Ship / Shore
Resume Load / Disch (3)
Completed Load / Disch
Reduced Load / Disch rate order by Ship / Shore
Continues to Agreement Rate Load/ Disch (1)
Cargo Hose Disconnected
Ships Paper & Cargo Document on Board
Commenced Bunker
Completed Bunker
Cast Off
Anchor at Inner Anchorage
Pilot On Board
Anchor Up
Actual Time Departure / Sailed
:
:
:
:
:
HOUR
Next Port
ETA
Draft on
Arrival
Departure
TOTAL
PART
TIME
:
:
Fwd
Mean
Aft
:
:
Mtr
Mtr
REMARKS
B
A
B
A
C
A
A
/
C
C
B
Grade
MFO
MDO
HSD
FW
LO
A
A
B
A
SHORE FIGURE (BL / AR)
ROB Bunker (Metric Ton)

Arrv.
Repl.
Dept.
SHIP FIGURE (AL / BD)
GRADE
KL Obs
KL 15C
Bbls 60F
LT
MT
TOTAL TIME FOR :
Explanation of Delay :
From :
From :
From :
SHIP (A) :
To :
To :
To :
Representative
AGENT (B) :
SHORE (C) :
:
:
:
MT/ TT
MASTER
PORT TIME
LAYTIME USED
LAYTIME ALLOWED
EXCESS TIME
HRS
HRS
HRS
HRS
TH
Phone : (62-21) 3816367, 3816314, 3816339, 3816353, 3816217. Fax : 3455430, 3816348, 3507121
ULLAGE / SOUNDING - REPORT

M/T
VOYAGE
DATE
PORT
DRAFT
Mtr
Mtr
Mtr
ULLAGES /
*
SOUND
(CM)
TANK NO
OBSERVED
DENSITY
TEMP( C)
o
C
o
15
TEMP
o
CARGO ( C)
GRADE
REMARKS
1
2
3
PORT
CENTER
STBS
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
Note: If any compartement used for ballast tank or empty, must be explained in the remarks column
.
CHIEF OFFICER
choose one of two

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LAMPIRAN III

Standard Formulir Aktivitas Kapal

PT. PERTAMINA (PERSERO)

This is to certify that MT / SS / TB :

Marine Fuel Oil

(For and on behalf of Charterer)

(For and on behalf of Owner)

PT. PERTAMINA (PERSERO)

RECEIVING AVAILABILITY AND CAPACITY

Line(LA) use &

Total Quantity Load/ Discharge =

, have inspected all ships tanks

And ready to commence loading of the cargo

Notes: Oil Inspector for Cleanliness :

Oil Inspector/ Loading Master

Mualim I / Chief Officer

SURAT PERBEDAAN ANGKA MUATAN

Setelah pengecekan kembali dengan teliti figures

After having been rechecked the figures of the

No. dan angka B/L

Berdasarkan figures tersebut diatas dengan ini kami

Base on above mentioned figures, we here by

Tanker Ullage Report pertama dan kedua diukur

The first and the second Tanker Ullage Report

As recorded, that my vessel is capable to loading / discharging cargo at

inches connection. However, shore can only supply /receive of

hours actual loading /discharging time.

In view of the foregoing, I Master of MT

protest the delay of

loading / discharging and on behalf of my Owners and Consignee / Charterer reserves

Master / Duty Officer

Cargo Load / Disch. (Long Ton)

Fuel & FW Consumption (MT)

Cargo Load / Disch. (Long Ton)

St. by. Eng. (EOSV)

Fuel & FW Consumption (MT)

Deviation to storing and / or repair port :

Fuel & FW Counsumption (MT)

Fuel & FW Counsumption (MT)

Distance to go at time of deviation to next loading / discharging port :

RE : DEPARTURE MASTER CABLE

THANKS FOR YOUR ATTENTION COOPERATION ACK REGARDS.

MARINE FUEL OIL

MARINE DIESEL FUEL

And charge same to my Principals namely :

I require the grades to be supplied in the following order :

Your very truly

Approximate amount/Bill of Lading quantity

Very truly yours

OFF HIRE CERTIFICATE

hours local time, on

*)coret yang tidak perlu

(For and on behalf of Owner)

LAPORAN PEMERIKSAAN PENCEGAHAN TUMPAHAN MINYAK DI PERAIRAN

Apakah talang penadah tumpahan

Slang terakhir telah terpasang

Apakah talang penadah tumpahan

*)coret yang tidak perlu

(For and on behalf of Owner)

(For and on behalf of Owner)

PUMPING / DISCHARGE LOG

AVERAGE PRESS MAINTAINED SHIP RAIL

NORMAL SERV. RPM