SHIPPER'S DECLARATION FOR DANGEROUS GOODS

Shipper
PT. JVD Indonesia (DGEX Indonesia), Soewarna Integrated Air Waybill No. 160 - 5314 1712/JNRT-GCL0212
Business Park, E10, Block B, Lot 7-8, Soeta Int'l Airport
Tangerang 15126 Indonesia, Tel : (+6221) 5591 1067, For: Page 1 of 1 Pages
PT. Bina Guna Kimia (FMC)
Wisma Kodel Lt. 10, Jl. H.R. Rasuna Said Kav. B-4 Shipper's Reference Number 5646-060918-OFA112
Jakarta 12910, Indonesia, Tel : (62-21) 522 2350 (optional)

Consignee
FMC Chemicals Kabushiki Kaisha
8F Otemachi Park Building
1-1-1 Otemachi, Chiyoda-Ku, Tokyo
100-0004 Japan
Tel : +81-3-5208-1010
Attn : Kasumi Araki-San
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 : Narita, Japan 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 3082 Environmentally hazardous substance, 9 III 2 Plastic Drums x 200 L 964
liquid, n.o.s. (Bifenthrin) Overpack Used x 12
#OFA112-A #OFA112-B
#OFA112-C #OFA112-D
#OFA112-E #OFA112-F
#OFA112-G #OFA112-H
#OFA112-I #OFA112-J
#OFA112-K #OFA112-L
Total Quantity
per Overpack 400 L

1 Plastic Drum x 200 L

Overpack Used
#OFA112-M
Total Net Quantity 200 L
16
17
18
19
20
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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, September 7, 2018
requirements have been met.
Signature
(see warning above)

Copyright © 2018 DGEX Indonesia