Details Applicant
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Details application
n Road n Railway n Inland waterway n Sea n Air
Contact details transport
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1.1 Official name of the organisation 1.2 Name contact person
1.3 Address
1.4 Postcode and place 1.5 Country
1.6 Postal address 1.7 Postcode and place 1.8 Country
1.9 Telephonenumber(s) 1.10 E-mailaddress
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2.1 To apply for an exemption for the transport by
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3.1 Name shipper 3.2 Address
goods
With this form you apply for an exemption for the transport of dangerous goods by road, railway, water or air.
The application must be filled in, provided with the necessary enclosures and forwarded at least 10 days prior to the desired date of transport.
The sections 8, 9, 10, 11 and 12 only have to be filled in for the type of transport on which the application applies to.
As soon as the Inspectorate receives your application, we will send you an invoice. The application will be conducted after payment of the invoice is received. The costs can change on a yearly basis, look at the website for the tariffs.
Incomplete or incorrectly filled out forms (including absence of additional documents) will not be processed.
Send the form to gsinfo@ilent.nl or send to
Inspectie Leefomgeving en Transport / Water, Produten en Stoffen P.O. Box 16191, 2500 BD Den Haag
In case of transport of Dangerous Goods by air, send the complete filled in form by e-mail to dgmelding@ilent.nl
Additional information 088 489 00 00 | www.ilent.nl
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Details dangerous goods
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3.6 Telephone calamities 3.7 Name of the operator 3.8 Address
3.9 Postcode and place 3.10 Country
3.11 Name contact person 3.12 Telephone calamities 3.13 Name addressee 3.14 Address
3.15 Postcode and place 3.16 Country
3.17 Name contact person 3.18 Telephone calamities 3.19 Name cargo handling agent 3.20 Address
3.21 Postcode and place 3.22 Country
3.23 Name contact person 3.24 Telephone calamities
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4.1 Proper shipping name, including technical name (if applicable) 4.2 UN or ID number
4.3 Class/Division/
Compatibilitygroup 4.4 Subsidiary risk (if applicable) 4.5 Packing group (If applicable) 4.6 Packing Instruction 4.7 Number of packaging 4.8 Type of packaging 4.9 UN marking
4.10 Net quantity per package 4.11 Gross mass per package 4.12 Total gross mass of the shipment 4.13 Class 1: total net explosive quantity
4.14 Tank- (container) number
Present location
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Place of destination
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Date of transport
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Details transport by road
n Packaged goods n Tank(container) n Bulk
Details transport railway
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Details transport inland waterway
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n Container vessel n Dry bulk ship n Tankship
n Type G n Type C n Type N
n Pressure tank n Closed n Open cargo tank with flame arresters n Open n Independent cargo tank n Integral cargo tank n Cargo tank wall distinct from the hull
Details transport by sea
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Details transport by air
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5.1 Full name
5.2 Address (no PO Box) 5.3 Postcode and place 5.4 Country
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6.1 Full name
6.2 Address (no PO Box) 6.3 Postcode and place 6.4 Country
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7.1 What is the forseen date of transport
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8.1 Type of roadtransport
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9.1 Wagon number
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10.1 Name of vessel and Europenumber 10.2 Type of vessel 10.3 Tankship type 10.4 Cargo tank design 10.5 Cargo tank type
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11.1 Name seavessel 11.2 Type of vessel
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12.1 Aircraft registration number 12.2 Aircraft type (PAX / CAO) 12.3 Air waybill number
12.4 Airport and state of departure 12.5 Airport and state of transit
(if applicable)
12.6 Airport and state of final destination
References
Motivation
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13.1 Indicate from which provisions of the rules exemption or approval should be granted (reference numbers or subjects)
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14.1 Provide motivation for the application of the exemption / approval
Equivalent safety measures
Enclosures
- Material safety data sheet (MSDS)
- Classification approval by competent authority (required for n.o.s. enteries in Class 1) - Copy test report of packaging
- Copy exemptions / approvals other countries
- Copy “Shippers Declaration for Dangerous Goods” (for the transport by air)
- Copy “Multimodal Dangerous Goods Form” (for the transport by road, railway and water )
Signature
I declare that all required information has been provided completely and truthfully.
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15.1 Which equivalent safety measures will be taken for this transport by or on behalf of the applicant
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16.1 The following documents must be enclosed with the application
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17.1 Name 17.2 Place and date
17.3 Signature applicant
