SHIPPER'S DECLARATION FOR DANGEROUS GOODS

Shipper
PT. JVD Indonesia (DGEX Indonesia), Soewarna Integrated Air Waybill No.
Business Park, Warehouse Area, Blok B, Lot 7-8, Unit E-10
Tangerang 19110 Indonesia, Tel: (+6221) 5591 1067, For: Page 1 of 1 Pages
PT Energi Sejahtera Mas, Dusun Nerbit Kecil
Lubuk Gaung, Sungai Sembilan, Dumai Shipper's Reference Number 2773-150518-A112
Riau 28826, Telp: (62-765) 7151000 / 5408 (optional)

Consignee
Cepsa-Centro De Investigation
Laboratorio De Analisis Elemental
Maria Del Mar Bermejo Avenida Punto, Com I Parque
Tecnoalcala 28805, Spain
Telp: +34 918304854, Email: begona.lamothe@cepsa.com
Attn: Begona Lamonthe Torres
Two completed and signed copies of this Declaration must WARNING
be handed to the operator.
TRANSPORT DETAILS Failure to comply in all respects with the applicable
This shipment is within the Airport of Departure: Dangerous Goods Regulations may be in breach
limitations prescribed for: of the applicable law, subject to legal penalties.
(delete non-applicable)
PASSENGER CARGO Soekarno - Hatta, Indonesia
AND CARGO AIRCRAFT
AIRCRAFT ONLY

Airport of Destination : Madrid, Spain Shipment type : (delete non-applicable)

NON-RADIOACTIVE RADIOACTIVE

NATURE AND QUANTITY OF DANGEROUS GOODS

Dangerous Goods Identification
UN Class Quantity and Packing
Pack- Authorization
Or Or Division type of packing Inst.
Proper Shipping Name ing
ID (Subsidiary
Group
No. Risk)
UN 3077 Environmentally hazardous substance, 9 III 1 Fibreboard Box x 1 Kg 956
solid, n.o.s. (TETRADECANOL)
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Additional Handling Information

24 Hour Emergency Contact Number: +62 823 7807 4550, +62 812 1047 2002, Contact Person : Arif Tawil
IATA Certificate No: 278100, SKP No: 0010669/DG.A2/DKP/XI/2016, Comp Certificate: 1168/DG-PTC/XII/16

I hereby declare that the contents of this consignment are fully and Name/Title of Signatory
accurately described above by the proper shipping name, and are classified,
packaged, marked and labelled/placarded, and are in all respects in proper Arif Tawil / Operation Specialist
condition for transport according to applicable International and national Place and Date
governmental regulations. I declare that all of the applicable air transport
Jakarta, May 21, 2018
requirements have been met.
Signature
(see warning above)

Copyright © 2018 DGEX Indonesia