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ANGLO-EASTERNGROUPQHSE MANAGEMENT

MT ATLANTIC GRACE

SHIP/ SHORE SAFETY CHECKLIST - TANKERS

No.:D/TNKR/02 Da!: 0" A#$ %2 R!&'('o): * P$!#: Ma(!$ A##$: S+#, Pa! % o

A'o): F'1! Lo

INSTRUCTIONS FOR COMPLETION:

Responsibility and accountability for the statements within the Ship/Shore Safety Check List is assigned within thedocument. The acceptance is confirmed by ticking or initialing the appropriate box and finally signing thedeclaration at the end of the Check list. Grayedout boxes are used to identify statements that generally may notbe applicable to one party! although the ship or terminal may tick or initial such sections if they so wish.

The presence of the letters A! Por Rin the column "code# indicates the following$A%"&greement#'. This indicates that the referenced consideration should be addressed by an agreement orprocedure that should be identified in the "Remarks# column of the Check List! or communicated in some othermutually accepted form.

P%"(ermission#'. )n the case of a negati*e answer to the statements coded "(#! no operations are to be conductedwithout the written permission from the appropriate authority.R%"Recheck#'. This indicates items to be rechecked at appropriate inter*als! as agreed between both partiesand stated in the declaration.

S3'#4( Na5! ..A1a)' G$a!6..

7!$3 66666666.. Po$ 666666666..

Da! o A$$'&a1 66666666.. T'5! o A$$'&a1 666666666..

PART 8A4 9 7ULK LIQUID GENERAL 9 PHYSICAL CHECKS

7+1 L';+', - G!)!$a1 S3'# T!$5')a1 Co,! R!5a$(

+. There is safe access between theship and shore.

R ame$Sardar SiraIul )slam >ame$

Rank$C/F Rank$

Signature$ Signature$

?ate$ Time$ ?ate$ Time$

R!o$, o $!#!''&! 3!(:

?ate$

Time$

)nitials for Ship$

)nitials for Shore$

?ate$

Time$

)nitials for Ship$

)nitials for Shore$

?ate$

Time$

)nitials for Ship$

)nitials for Shore$

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