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Cg 4260 R Ev 6 04 Form 2004
CODE
OF AGENT OR
CHARTERER
DATE(S) AND
TIME(S) OF
OPERATION
I UNDERSTAND and will comply with current safety laws, rules and regulations of the United States, the State,
County, City and Port Authority while handling hazardous materials. (See Page 2.)
TITLE (Authorized Company
Representative)
DATE
SIGNATURE
PERMIT
THE ABOVE REQUEST IS:
APPROVED
APPROVED WITH THE FOLLOWING CONDITIONS
EXCEPTIONS/CONDITIONS
DATE
SIGNATURE (Captain of the Port, U.S. Coast Guard)
INSPECTION (VESSEL LOADING...
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