Form Approved
TANKER / BARGE MATERIAL INSPECTION
OMB No: 0704-0248
AND RECEIVING REPORT
Public reporting burden for this collection of information is estimated to average 35 minutes per response, including the time for reviewing instructions, searching existing data
sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other
aspect of this collection of information, including suggestions for reducing this burden, to Washington Headquarters Services, Directorate for Information Operations and
Reports, 1215 Jefferson Drive Highway, Suite 1204, Arlington VA 22202-4302, and to the Office of Management and Budget, Paperwork Reduction Project (0704-0248),
Washington DC 20503.
1. TANKER / BARGE
2. INSPECTION OFFICE
3. REPORT NUMBER
LOADING REPORT
DISCHARGE REPORT
4. AGENCY PLACING ORDER ON SHIPPER, CITY, STATE, AND/OR LOCAL ADDRESS (Loading)
5. DEPARTMENT
6. PRIME CONTRACT OR P.O NUMBER
7. NAME OF PRIME CONTRACTOR, CITY, STATE, AND/OR LOCAL ADDRESS (Loading)
8. STORAGE CONTRACT
9. TERMINAL OR REFINERY SHIPPED FROM, CITY, STATE AND/OR LOCAL ADDRESS (Loading)
10. ORDER NUMBER ON SUPPLIER
11. SHIPPED TO (Receiving Activity, City, State and/or Local Adress)
12. B / L NUMBER
13. REQN./REQUEST
14. CARGO NO.
NO.
15. VESSEL
16. DRAFT ARRIVAL
17. DRAFT SAILING
FORE
AFT
FORE
AFT
18. PREVIOUS TWO CARGOES
19. PRIOR INSPECTION
FIRST
SECOND
20. CONDITION OF SHORE PIPELINE
21. APPROPRIATION (Loading)
22. CONTRACT ITEM NO.
23. PRODUCT
24. SPECIFICATIONS
25.STATEMENT OF QUANTITY
LOADED
DISCHARGED
LOSS/GAIN
PER
CENT
BARRELS (42 Gals) (Net)
TABLE 52
GALLONS (Net)
LITER AT 15,,C
26.
STATEMENT OF QUALITY
TESTS
SPECIFICATION LIMITS
TEST RESULTS
27. TIME STATEMANT (LOCAL)
DATE
TIME
28. REMARKS (Note in detail cause of delays such as repairs,
breakdown, slow operation, stoppage, etc.)
NOTICE OF READINESS TO DISCHARGE
VESSEL ARRIVED IN ROADS
MOORED ALONGSIDE
STARTED BALLAST DISCHARGE
FINISHED BALLAST DISCHARGE
INSPECTED AND READY TO DISCHARGE
CARGO HOSES CONNECTED
COMMENCED DISCHARGE
STOPPED DISCHARGE
RESUMED DISCHARGE
FINISHED DISCHARGE
CARGO HOSES REMOVED
VESSEL RELEASED BY INSPECTOR
29. COMPANY OR RECEIVING TERMINAL
COMMENCED BUNKERING
FINISHED BUNKERING
___________________________________
VESSEL LEFT BERTH
(Signature)
30. I CERTIFY THAT THE CARGO WAS INSPECTED, ACCEPTED
31. I HEREIN CERTIFY THAT THIS TIME STATEMENT IS CORRECT
AND DISCHARGED AS INDICATED HEREON.
_______
___________________________________________
_____________________________________________________
(Date)
(Signature of Authorized Government Representative)
(Master or Agent)
DD Form 250-1, JAN 90
Figure 4-1. DD Form 250-1 (Tanker/Barge Material Inspection and Receiving Report).
QM 5184
4-6
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