VBG Bijlage 1a ADN - RBV advies

* FOR DANGEROUS GOODS: you must specify: UN No., proper shipping name, hazard class, packing group (where assigned) and any other element of information requiredMULTIMODAL DANGEROUS GOODS FORM1. Shipper / Consignor /Sender 2. Transport document number3.4. Shipper's referencePage 1 of Pages5. Freight Forwarder's reference6. Consignee 7. Carrier (to be completed by the carrier)SHIPPER'S DECLARATIONI hereby declare that the contents of this consignment are fully and accurately described below by theproper shipping name, and are classified, packaged, marked and labeled /placarded and are in allrespects in proper condition for transport according to the applicable international and nationalgovernmental regulations.8. This shipment is within the limitations prescribed for: (Delete 9. Additional handling informationnon-applicable)PASSENGER ANDCARGO AIRCRAFTCARGOAIRCRAFT ONLY10. Vessel / flight no. and date 11. Port / place of loading12. Port / place of discharge 13. Destination14. Shipping marks *Number and kind of packages; description of goods Gross mass (kg) Net mass Cube (m3)under applicable national and international regulations15. Container identification No./vehicle registration No.CONTAINER/VEHICLE PACKING CERTIFICATEI hereby declare that the goods described above have beenpacked/loaded into the container/ vehicle indentified above inaccordance with the applicable provisions **MUST BE COMPLETED AND SIGNED FOR ALL CONTAINER/VEHICLE LOADS BY PERSON RESPONSIBLE FOR PACKING/LOADING16. Sealnumber (s)17. Container/vehiclesize & type18.Tare (kg) 19.Total gross mass(inlcuding tare) (kg)21.RECEIVING ORGANISATION RECEIPTReceived the above number of packages/containers/trailers in apparentgood order and condition unless stated hereon: RECEIVINGORGANISATION REMARKS:20. Name of company Haulier's name 22. Name of company (OF SHIPPER PREPARING THIS NOTE)Name / Status of declarant Vehicle reg. no. Name / Status ofdeclarantBLACK HATCHINGS BLACK HATCHINGS BLACK HATCHINGS BLACK HATCHINGS BLACK HATCHINGS BLACK HATCHINGSPlace and dateSignature of declarantSignature anddateDRIVER'SSIGNATUREPlace and dateSignature of declarant** See 5.4.2.ADN HOOFDSTUK 5.4 – 2009 5.4 - 17