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Bunker Sample Vessel Name IMO No. Date (dd/mm/yy) Port or Location Supplier Barge Name/Shore Tk/Other
Bunker Sample
Vessel Name
IMO No.
Date (dd/mm/yy)
Port or Location
Supplier
Barge Name/Shore Tk/Other
Sampling point
Other:
Vessel manifold
Bunker Barge Pipeline
Sampling Method :
Continuous drip
Composite of spots
Spot
Automatic
Grade Ordered:
Density:
Viscosity:
Sulfur:
Quantity MT:
Remarks:
Sample distribution/Seals :
To Laboratory
To Suppliers Rep.
To Vessel -
Retained on board
(MARPOL Annex
VI)
Retained sample
Signatures
Vessel’s Repr.
Supplier’s Repr.
Surveyor (if applicable)
Name(print)
Name(print)
Name(print)
Signature
Signature
Signature
VPS/LBL001/R01_0316
Bunker Sample Vessel Name IMO No. Date (dd/mm/yy) Port or Location Supplier Barge Name/Shore Tk/Other
Bunker Sample
Vessel Name
IMO No.
Date (dd/mm/yy)
Port or Location
Supplier
Barge Name/Shore Tk/Other
Sampling point
Other:
Vessel manifold
Bunker Barge Pipeline
Sampling Method :
Continuous drip
Composite of spots
Spot
Automatic
Grade Ordered:
Density:
Viscosity:
Sulfur:
Quantity MT:
Remarks:
Sample distribution/Seals :
To Laboratory
To Suppliers Rep.
To Vessel -
Retained on board
(MARPOL Annex
VI)
Retained sample
Signatures
Vessel’s Repr.
Supplier’s Repr.
Surveyor (if applicable)
Name(print)
Name(print)
Name(print)
Signature
Signature
Signature
VPS/LBL001/R01_0316
Bunker Sample Vessel Name IMO No. Date (dd/mm/yy) Port or Location Supplier Barge Name/Shore Tk/Other
Bunker Sample
Vessel Name
IMO No.
Date (dd/mm/yy)
Port or Location
Supplier
Barge Name/Shore Tk/Other
Sampling point
Other:
Vessel manifold
Bunker Barge Pipeline
Sampling Method :
Continuous drip
Composite of spots
Spot
Automatic
Grade Ordered:
Density:
Viscosity:
Sulfur:
Quantity MT:
Remarks:
Sample distribution/Seals :
To Laboratory
To Suppliers Rep.
To Vessel -
Retained on board
(MARPOL Annex
VI)
Retained sample
Signatures
Vessel’s Repr.
Supplier’s Repr.
Surveyor (if applicable)
Name(print)
Name(print)
Name(print)
Signature
Signature
Signature
VPS/LBL001/R01_0316
Bunker Sample Vessel Name IMO No. Date (dd/mm/yy) Port or Location Supplier Barge Name/Shore Tk/Other
Bunker Sample
Vessel Name
IMO No.
Date (dd/mm/yy)
Port or Location
Supplier
Barge Name/Shore Tk/Other
Sampling point
Other:
Vessel manifold
Bunker Barge Pipeline
Sampling Method :
Continuous drip
Composite of spots
Spot
Automatic
Grade Ordered:
Density:
Viscosity:
Sulfur:
Quantity MT:
Remarks:
Sample distribution/Seals :
To Laboratory
To Suppliers Rep.
To Vessel -
Retained on board
(MARPOL Annex
VI)
Retained sample
Signatures
Vessel’s Repr.
Supplier’s Repr.
Surveyor (if applicable)
Name(print)
Name(print)
Name(print)
Signature
Signature
Signature
VPS/LBL001/R01_0316
Bunker Sample Vessel Name IMO No. Date (dd/mm/yy) Port or Location Supplier Barge Name/Shore Tk/Other
Bunker Sample
Vessel Name
IMO No.
Date (dd/mm/yy)
Port or Location
Supplier
Barge Name/Shore Tk/Other
Sampling point
Other:
Vessel manifold
Bunker Barge Pipeline
Sampling Method :
Continuous drip
Composite of spots
Spot
Automatic
Grade Ordered:
Density:
Viscosity:
Sulfur:
Quantity MT:
Remarks:
Sample distribution/Seals :
To Laboratory
To Suppliers Rep.
To Vessel -
Retained on board
(MARPOL Annex
VI)
Retained sample
Signatures
Vessel’s Repr.
Supplier’s Repr.
Name(print)
Name(print)
Surveyor (if applicable)
Name(print)
Signature
Signature
Signature
VPS/LBL001/R01_0316
Bunker Sample Vessel Name IMO No. Date (dd/mm/yy) Port or Location Supplier Barge Name/Shore Tk/Other
Bunker Sample
Vessel Name
IMO No.
Date (dd/mm/yy)
Port or Location
Supplier
Barge Name/Shore Tk/Other
Sampling point
Other:
Vessel manifold
Bunker Barge Pipeline
Sampling Method :
Continuous drip
Composite of spots
Spot
Automatic
Grade Ordered:
Density:
Viscosity:
Sulfur:
Quantity MT:
Remarks:
Sample distribution/Seals :
To Laboratory
To Suppliers Rep.
To Vessel -
Retained on board
(MARPOL Annex
VI)
Retained sample
Signatures
Vessel’s Repr.
Supplier’s Repr.
Name(print)
Name(print)
Surveyor (if applicable)
Name(print)
Signature
Signature
Signature
VPS/LBL001/R01_0316
Name(print) Name(print) Surveyor (if applicable) Name(print) Signature Signature Signature VPS/LBL001/R01_0316