Title Page

  • Company

  • Location
  • Certified Fumigant Applicator

  • Conducted on

Fumigation Report

General Information

  • Vessel Name

  • Country of Loading

  • Country of Discharge

  • Estimated Voyage Time (in days)

  • Commodity

  • Specify

  • Gross Weight (in KG)

  • Quantity (in CTNS)

Holds or Tanks treated:

  • Depth

  • Cubic Capacity

  • Type & Quantity of Fumigation Formulation Used

  • Dosage of Exposure

  • Method of Application

Sign Off

  • Additional Observations

  • I certify that immediately following application of the fumigant formulation all openings to the fumigated space were closed and placarded with appropriate warning signs. I further certify that all openings to the fumigated space have been checked and no fumigant gas was leaking at the time of the vessel’s departure.

  • Certified Fumigant Applicator Name & Signature

  • Officer in Charge Name & Signature

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