MULTIMODAL DANGEROUS GOODS FORM

This form may be used as a dangerous goods declaration as it meets the requirements of SOLAS 74, chapter VII, regulation 5; MARPOL 73/78,Annex III,
regulation 4 and section 9 of the General Introduction to the IMDG Code.
1. Shipper 2. Transport document number
XXXXXXX_xxxxxxxxx_xxxxxxxxx
xxxxxxxxx 3. Page of pages 4. Shipper’s reference
1/1
5. Freight forwarder’s reference
6. Consignee 7. Carrier (to be completed by the carrier)
xxxxxxxxssssSSSS. XXXXXXXXXXX
XXXXXXXXXX, 23200 La Carolina, Jaén - SPAIN

8. This shipment is within the limitations
prescribed for: (Delete non-applicable)
10. Vessel/flight no. and date
12. Port/place of discharge
14. Shipment information Number and kind of packages; description of goods (*see bottom)
IMO NO. (Sub risk if have): N/A
UN NO.: 3496
Proper shipping name: Nickel Metal Hydride batteries
SHIPPER’S DECLARATION
I hereby declare that the contents of this consignment are fully and accurately
described below by the proper shipping name, and are classified, packaged, marked
and labeled/placarded and are in all respects in proper condition for transport
according to the applicable international and national government regulations.
9. Additional handling information
24 hr Emergency contact person :
24 hr Emergency contact telephone:
11. Port/place of loading EMS :F-A, S-I
Hong Kong
13. Destination
SPAIN

Technical name (if have):

Packing group (if have): N/A
Flash point (if have): N/A
Marine pollutant (P or N): N/A
Boiling point (if have): N/A
Package quantity and type: 34 cartons
Packing Code: 4G
Inner package quantity and type (if have): box
Gross Weight (KGS): 367
Net Weight (KGS): 331
Limited quantity (Y or N): -N

15. Container number. 16. Seal number(s) 17.Container Size & type 18. Tare mass (kg)

CONTAINER/VEHICLE PACKING CERTIFICATE 21. RECEIVING ORGANIZATION RECEIPT

I hereby declare that the goods described above have
been packed/loaded into the container/vehicle identified Received the above number of packages/containers/trailers in apparent good
above in accordance with the applicable provisions. ** order and condition, unless stated hereon: RECEIVING ORGANISATION
MUST BE COMPLETED AND SIGNED FOR ALL REMARKS:
CONTAINER/VEHICLE LOADS BY PERSON RESPONSIBLE
FOR PACKING/LOADING
20. Name of company 22. Name of company

Name/status of declarant Signature and date Name/status of declarant

Lily Feng Lily Feng

Place and date Place and date

Dongguan factory Dongguan factory

Signature of declarant DRIVER’S SIGNATURE Signature of declarant

* DANGEROUS GOODS:
You must specify: UN No., proper shipping name/correct technical name, IMO hazard class (subrisk), Packaging group (where assigned), Marine