med.inventory 06.2010

15
Reider Shipping B.V. Lloyd-Apotheke Zeefbaan 20c Bgm.-Smidt-Str. 170 9672 BN Winschoten 27568 Bremerhaven The Netherlands Phone: ++49/471/946070 Fax: ++49/471/94607-13 Inventory and Stock List Date: June 30, 2010 Vessel: Flag: Antigua & Barbuda Number of crew and passengers on board: Crew - 12 / PAX - nil Trading area: Caribbean Sea Medicine chest certificate valid until: May 15, 2011 Inventory and Stock list of medical equipment mentioned in the DUTCH "GENEESKUNDIG HANDBOEK VOOR DE SCHEEPVAART" AFL. 6 valid from 16. July 2006 including the provisions of Directive 92/29/EEC and IMO Resolution MSC/Circ. 857 including Equipment for ships carrying dangerous goods and/or containers: IMDG Code 2006 Edition as agreed between your company and Lloyd-Pharmacy [email protected] m/v WESTERHAVEN

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Page 1: Med.inventory 06.2010

Page 1 of 13 Encl. 45 Rev. 3

Reider Shipping B.V. Lloyd-ApothekeZeefbaan 20c Bgm.-Smidt-Str. 1709672 BN Winschoten 27568 BremerhavenThe Netherlands Phone: ++49/471/946070

Fax: ++49/471/94607-13

Inventory and Stock List Date: June 30, 2010

Vessel:Flag: Antigua & BarbudaNumber of crew and passengers on board: Crew - 12 / PAX - nilTrading area: Caribbean SeaMedicine chest certificate valid until: May 15, 2011

Inventory and Stock listof medical equipment mentioned in the DUTCH "GENEESKUNDIG HANDBOEK VOOR DE SCHEEPVAART" AFL. 6valid from 16. July 2006 including the provisions of Directive 92/29/EEC and IMO Resolution MSC/Circ. 857

including Equipment for ships carrying dangerous goods and/or containers: IMDG Code 2006 Editionas agreed between your company and Lloyd-Pharmacy

[email protected]

m/v WESTERHAVEN

Page 2: Med.inventory 06.2010

Page 2 of 13 Encl. 45 Rev. 3

Pos Description Storage Stock on board Expiry date

B3.1 Cardiovascular1.1.01 Digoxine tablet 0,25 mg 50 20 50 Jan-2011

1.1.02 Adrenaline ampoule 1 mg/1 ml (im, iv and sc injectable) 10 6

1.2.02 Isosorbide-dinitrate tablet 5 mg 30 2030 Jan-2012

1.3.01 Frusemide tablet 40 mg 20 20 20 Dec-2010

1.3.03.H Frusemide ampoule 40 mg/4 ml (im and iv injectable) 5 105 Nov-2010

5 Dec-2011

1.4.02.H Phytomenadione ampoule 10mg/1 ml (im injectable) 10 10 10 Nov-2010

1.4.03 Oxytocin 5mg injection 10X1ml amp. 5 6 10 Dec-2011

1.5.01 Nifedipine capsule 10 mg 30 30 30 Apr-2011

1.5.02 Metoprolol 50 mg tablets 30 60 Nov-2012

1.6.02 Calcium carbasalate 100 mg or Acetyl salicyxlic acid tablet 100 mg 50 20 50 Nov-2010

B3.2 Gastro-Intestinal System

2.1.03 Cimetidine tablet 400 mg 20 60

2.1.04 Algeldrate + magnesium hydroxide suspension, bottle 300 ml 20 x 10 ml 600400 Nov-2012200 Nov-2010

2.1.05 Omeprazole 20 mg tablets or capsules 30 60 60 Dec-2010

2.2.02 Domperidone suppository 60 mg / Metoclopramide 10mg supp. 5 1810 Oct-2010

10 Dec-2011

2.2.03.H Metoclopramide ampoule 10mg/2 ml (im injectable) 5 3020 Oct-201310 Jan-2015

2.3.01 Lactulose syrup 200 ml 600 600 Nov-2012

2.3.02 Sodium aurylsulfoacetate / Sorbitol Sodium citrate rectal dispender 5 ml 12 12 12 Feb-2013

2.4.01 Loperamide capsule 2 mg 10 80 10+20 Sep-2012/Oct-2013

2.6.01 Vaseline / Lidocaine ointment, 3%, tube 30 g 50 g 60 60 Jan-2013

B3.3 Analgesics and Anti-Spasmodics3.1.02 Ibuprofen coated tablet 400 mg 20 40 36/20 Aug.2010 / Jan.2013

3.1.03.H Paracetamol tablet 500 mg 100 200

100 Aug-2013

20 May-2011

100 Aug-2011

3.2.03.H Morphine HCl ampoule 2ml (im and sc injectable) SAFE 10 40 40 Dec-2011

3.3.02 Diclofenac suppository 100 mg 10 10 10 Aug-20123.4.01.H Naloxon ampoule 0,4 mg/1 ml (im and iv injectable) 3 6 3+3 Oct.2010 / Jan.2012

Package unitpcs/ml/gs

Recommendedquantities for

up to 15 persons

New supply:only decided

by pharmacist

Page 3: Med.inventory 06.2010

Page 3 of 13 Encl. 45 Rev. 3

Pos Description Storage Stock on board Expiry datePackage unitpcs/ml/gs

Recommendedquantities for

up to 15 persons

New supply:only decided

by pharmacist

B3.4 Nervous System

4.1.02.H Diazepam 10 mg suppositories SAFE 5 105 Jul-2011

5 Jun-2011

4.1.03 Oxazepam tablet 10 mg 20 20 20 Sep-2012

4.2.01 Haloperidol tablet 1 mg 20 20 20 Jun-20124.2.02 Haloperidol ampoule 5 mg/1 ml (im and iv injectable) 5 10 5 Feb-2015

4.3.02 Cyclizine suppository 150 mg 1010 Oct-2011

4.3.03 Cinnarizine tablet 75 mg 100 50 50 Feb-2013

4.4.02 Carbamazepine tablet 200 mg 50 20 50 Mar-2011

4.5.01 Temazepam tablet / capsule 10 mg 20 20 20 Jan-2012

B3.5 Anti-Allergics and Anti-Anaphylactics5.1.03 Clemastine tablet 1 mg 20 20 20 Oct-20115.1.04 Clemastine ampule 2 mg / 5 ml (im and iv injectable) 5 3 5+5 Oct.2010/Jan.20125.2.02 Dexamethasone ampoule 4 mg / 4 ml (im and iv injectable) 3 5 3+3 Sep.2010/Jan.2012

B3.6 Respiratory System6.1.02.H Salbutamol 0,1 mg / ds, inhaler 1 5 3+2 May.2011/Oct.2012

6.1.03.H Beclomethasone 0,05 mg/ds, inhalor 200 ds 1 55 May-2012

6.1.04 Volumatic device to be used with 6.1.02 and 6.1.03 1 2 2 unlimited

6.2.01 Dextromethorphan syrup, bottle 200 ml 100 ml 600 400+200 Dec.2010/Oct.2012

6.3.01 Xylomthazoline nasal drops 0,1%, dropper bottle 10 ml 10 ml 50 50 Jan-2013

B3.7 Anti-Infection7.1.01.H Amoxycillin tablet 500 mg 10 90 10+50+30 Dec-2010/Sep-2012 May-13

7.1.06.H Erythromycin tablet 500 mg 10 6040 Apr-2011

7.1.07 Doxycycline capsules 100 mg 20 20 10+20 Feb.2011/Sep.2012

7.1.08.1 Aqua dest ampoule 10ml 20 Dec-2011

7.1.08.H Cefuroxime ampoule 750 mg + 5 ml solvent (im injectable) 5 15 20 Feb-2011

7.2.02 Cotrimoxazole tablet 960mg 20 2020 Dec-2010

20 Nov-2012

7.4.02 Metronidazole tablet 400 mg 20 20 20 Nov-2012

7.4.03.H Metronidazole suppository or ovule 100 mg 10 2010 Jun-2014

7.5.01 Ciprofloxacine tablet 250 mg 10 40 20+10 Sep.2013/Sep.20147.6.01 Tetanus vaccine ampoule 0,5 ml (im injectable) Cool 1 5 5 Sep-20117.6.02 Tetanus immunoglobulin ampoule 250 U / 2 ml (im injectable) Cool 1 3 3+3 Dec.2010/Mar.2011

7.7.01.t Quinine sulphate tablet/coasted tablet 300 mg 20 7020 Sep-2010

7.7.02.t Proguanil tablet 100 mg 100 1000

Page 4: Med.inventory 06.2010

Page 4 of 13 Encl. 45 Rev. 3

Pos Description Storage Stock on board Expiry datePackage unitpcs/ml/gs

Recommendedquantities for

up to 15 persons

New supply:only decided

by pharmacist7.7.02.t Proguanil tablet 100 mg 100 1000

Page 5: Med.inventory 06.2010

Page 5 of 13 Encl. 45 Rev. 3

Pos Description Storage Stock on board Expiry datePackage unitpcs/ml/gs

Recommendedquantities for

up to 15 persons

New supply:only decided

by pharmacist

7.7.03.t Chloroquine phosphate tablet 250 mg 100 2007.7.04.t Quinine hydrochloride amp.600 mg/2 ml + Aqua dest.10amp.5ml. 20pcs 10 107.7.05.t Malarone ® 250/100 mg tablets 12 250

B3.8 Compounds Promoting Rehydration, Caloric intake and Plasma Expansion

8.1.01.H 10 4820 Dec-2013

20 Jan-2012

8.1.02.H NaCI 0,9% infusion, bottle 500 ml 1000 ml 50001000 Jul-2012

4000 Mar-2011

8.3.01.H 500 ml 50002500 Jul-2012

8.4.01.t NaCI tablet 400 mg + coating glucose 100 mg 500 500 500 Aug-2011

B3.9 Skin Medicines9.1.01 Povidone-Iodine solution, bottle 30 ml 100 ml 120

9.1.03 Chloorhexidine 0,5%, bottle 30 ml 50 ml 120100 Apr-2013

50 Dec-2012

9.1.04 Chloorhexidine / Cetrimide solution 150 ml 750250 May-2012

1000 Sep-2010

9.1.05 Ethanol 70% 500ml 886 nil

9.1.08 Betadine ointment, tube 25 g 25 g 10025 May-2011

25 Aug-2012

9.1.09 Capsicum compositum cream, tube 50 g 50 g 90 100 Jan-2011

9.1.10 Miconazole nitrate cream 2%, tube 15 g 15 g 120 120 Jan-2011

9.1.13 Silver Suphadiazine cream 1%, tube 50 g Cool 50 g 250 250 Jan-2011

9.1.15 Alumnis compositum powder, can 100 g 100 g 400400 Jul-2011

100 Dec-2010

9.1.18 Lanette/menthol cream 2% 20 g 20 20 Apr-2011

9.1.20 Permethrin lotion 10 mg/g , bottle 100 ml 50 ml 180

250 May-2011

50 Nov-2011

100 Aug-2012

9.1.21 Hydrocortisone cream 1% 15 g 6015 Sep-2011

20 Oct-2012

B3.10 Eye Medicines

9.2.03.H Tetracaine eyedrops 0,5% SDU Cool 20 2020 Dec-2013

9.2.03.2 Oxybuproc. hydrochlor. 4mg/ml 10ml 20 Apr-2011

9.2.04 Pilocarpine eyedrops 1% Cool 10 10 10 Nov-2011

9.2.05.H Fluorescein paperstrips 1% 10 10 10 Oct-2011

9.2.06.H Polymyxin-B/trimethoprim eye ointment Cool 5 g 40 10+15 Oct.2011/Mar.2012

9.2.07 Fusidic acid eyegel 1% unitdose 0,2 g Cool 3 g 249 Aug-2011

15 Oct-2010

Oral Rehydration Salts, WHO-formula, sachet to give 1 liter rehydration solution

Polygeline(Haemacel) infusion, bottle 500 mlIV giving set, see II.5.05e

Page 6: Med.inventory 06.2010

Page 6 of 13 Encl. 45 Rev. 3

Pos Description Storage Stock on board Expiry datePackage unitpcs/ml/gs

Recommendedquantities for

up to 15 persons

New supply:only decided

by pharmacist

B3.11 Ear Medicines9.3.02 Lidocaine eardrops 0,5% 10 ml 10

Page 7: Med.inventory 06.2010

Page 7 of 13 Encl. 45 Rev. 3

Pos Description Storage Stock on board Expiry datePackage unitpcs/ml/gs

Recommendedquantities for

up to 15 persons

New supply:only decided

by pharmacist

9.3.03 Neomycine/Polymyxine-B/Hydrocotisone eardrops 5 ml 20 10+10 Oct.2010/Sep.2011

B3.12 Medicines for oral and throat Injections9.4.01 Chlorhexidine mouthwash 2% 200 ml 400 200+200 Sep-2010/Dec-2011

B3.13 Local Anaesthetics9.5.01 Ethyl chloride liquid spray 1 1 1 May-2013

9.5.02 50 ml 4050 Jun-2012

9.5.03 Oleum carophylli (oil of cloves), dropper bottle 10 ml 10 ml 10 10 Nov-2011

B3.14 Additonal Antidotes

10.1.01.H Calcium gluconate gel 2% 20 g 25075 Mar-2013

10.2.05.H 10 20020 Jan-2012

10 Dec-2010

10.2.06.H Calcium gluconate effervescent 1 g 20 20 20 Mar-2011

10.2.09.H Activated charcoal, powder 61.5 g 10050 Apr-2013

61.5 Jun-2011

10.2.10.H Ethyl alcohol solution 96% & 95% 500 15001500 Jan-2014/Nov-2013

500 Nov-2010

Resuscitation-Equipment

II.1.01 1 2 2

II.1.02.a 1 1 1 May-2011

II.1.02.b Oxygen spare bottle, 2 ltr./200 bar 1 1 2 May-2011

II.1.02.c Oxygen cylinder 40 ltr / 200 bar 1 1 1 May-2011

II.1.03 Mechanical aspirator to clear upper respiratory pass. 1 1 1

II.1.04 Brook Airway Or Lifeway or equivalent 1 2 2

II.1.05.a Guedel airway (Mayo-tube) № 2 1 22 Oct-2011

1 Jan-2012

II.1.05.b Guedel airway (Mayo-tube) № 3 1 21 Oct-2011

1 Feb-2012

II.1.05.c Guedel airway (Mayo-tube) № 4 1 2 2 Aug-2011

II.1.06 Facemask disposable (up to 60 % oxygen) 1 1017 unlimited

Surgical-EquipmentII.2.02 Adhesive elastic bandage 4m / 6 cm 1 1 1

II.2.03.c Hydrolast bandage w/firm side, 4m / 6 cm 1 30 30

II.2.04 Tubular gauze bandage for finger dressing with applicator, 5m 4 5+2

Lignocaine 2%, bottle 50 ml, no adrenaline(sc and im injectable)

Atropine sulphate ampoule 1 mg/1 ml(im and iv injectable)

Manual resuscitator bag with demand valve and mask, including the resuscitator already present in II.1.02.a

Portable oxygen giving set, including 1 oxygen cylinder 2 ltr / 200 bar, manual resuscitator with extra mask

11

Page 8: Med.inventory 06.2010

Page 8 of 13 Encl. 45 Rev. 3

Pos Description Storage Stock on board Expiry datePackage unitpcs/ml/gs

Recommendedquantities for

up to 15 persons

New supply:only decided

by pharmacist

II.2.05.a Sterile gauze compresses 5 X 5 cm, sterille 2 160 130 Jul-2011

II.1.05.b Sterile gauze compresses 10 X 10 cm, sterille 2 75 38 Jan-2012

II.2.05.c Vaseline gauze deressing, 10 x 10 cm, sterille 1 2010 Dec-2010

9 Jan-2012

II.2.06 Absorbent cotton wadding, non-sterile, 100 g 1 4 4

II.2.07.a Metalline bad sheet 73 X 250 cm, sterile 1 1 1 Jan-2011

II.2.07.c Waterjel burndressing 60X80 cm Cool 1 2

II.2.08 Triangular sling (cotton wool), 96X96X136 cm 1 4 9

II.2.09.a Disposable polyethylene gloves, in pairs 1 12 12

II.2.09.b Surgical gloves size M, sterile, in pairs 1 3 3 Mar-2012

II.2.09.c Surgical gloves size L, sterile, in pairs 1 3 3 Sep-2011

II.2.10.b Adhesive wound-plaster, waterproof 6X10 cm 1 3 5(3+1+1) Sep-2011/Dec-2010 Mar-2013

II.2.11.a Sterile compression bandage № 1, small, 6 X 8 cm 1 42+1 Jun.2014/Dec.2014

1 Feb-2011

II.2.11.b Sterile compression bandage № 2, medium, 8 X 10 cm 1 10

5 Jun-2014

5 Apr-2011

1 May-2012

II.2.11.c Sterile compression bandage № 3, large, 10 X 12 cm 1 43 Dec-2014

1 Apr-2011

II.2.12.a Adhesive tape waterproof, 5 m x 1,5 cm 1 2 1

II.2.12.b Adhesive tape waterproof, 5 m x 2,5 cm 1 2 2

II.2.12.c Adhesive sutures/Butterfly bandage, sterile 3 20 3+7 Sep-2012/Apr-2011

II.2.13.c Sutures with non-traumatic needles vicryl 4-0 1 10 5 Feb-20155 Dec-2010

II.2.13.d Sutures with non-traumatic needles ethinol 3-0 1 10 5 Dec-2010

II.2.13.e Sutures with non-traumatic needles ethinol 5-0 1 10

5 Jun-20141 Dec-2010

5 Jun-2011

II.2.14 Undercast padding 1 4 10+2

II.2.15.a Eye shade with elastic head hand 1 2 3

II.2.15.b Pad, eye, cotton, sterile, 5 pieces 5 25 Jan-2013

1 Sep-2012

II.2.16 Safety pins rustless, 12 pcs 12 2 3

First Aid Dress ster. 8X10cm & small 7 Jun-2014

Adhesive sutures 6X75mm 3 Oct-2013

Durable Cotton Stretch Bandages,type ideal, with clips 8

InstrumentsII.3.01 Scalpel sterile disposable 1 3

II.3.02 Instrument box (Stainless-steel) 1 1 1

II.3.03.a Scissors surgical strait (Stainless-steel) 1 1 1

II.3.03.b Scissors lister, 18 cm (Stainless-steel), not to be stored in II.3.02 1 1 1

II.3.04.a Anatomical forceps, 14,5 cm (Stainless-steel) 1 1 1

Page 9: Med.inventory 06.2010

Page 9 of 13 Encl. 45 Rev. 3

Pos Description Storage Stock on board Expiry datePackage unitpcs/ml/gs

Recommendedquantities for

up to 15 persons

New supply:only decided

by pharmacist

II.3.04.b Dressing forceps, 14,5 cm 1 1 1

II.3.05 Artery forceps, type "Knocher", 14,5 cm 1 1 1

II.3.06 Needle holder, tape "Mathieu", 14,5 cm 1 1 1

II.3.07 Dispsable razor 1 5 10

II.3.08 Splinter forceps "Feilchenfeld", 11 cm 1 1 1

II.3.09 Ring forceps / Ring saw (Stainless-steel) 1 1 1

II.3.10 Eye spud for removal of foreign body 1 1 1

II.3.11 Eye cup for irrigation (plastic) 1 1 1

II.3.12 Gastric tube Ch. 21, sterile 1 1

Examination and monitoring equipmentII.4.01 Tongue depressors wood,disposable 100 50 50

II.4.02 Reactive strips for urine analysis: blood/glucose//proteine/ntrite/leucocytes 50 1 1+1 Sep.2010/Jan.2012

II.4.03 Temperature/pulse chart 1 20 20

II.4.04 Medical evaluation sheets 1 4 4

II.4.05 Stetoscope 1 1 1

II.4.06 Sphygmomanometer and stetoscope, automatically 1 1 2

II.4.07 Standard clinical thermometer 1 3 3

II.4.08 Hypothermic thermometer in container 1 1 1

II.4.09 Penlight type flash light + blue cover 1 2 2

Equipment for injection, perfusion, puncture and catheterizationII.5.02.a Rectal drip set, including 1 catheter 1 1 1 Dec-2010

II.5.02.b Catheter Ch 28 / 40 cm to be used with rectal drip set 1 64 Jan-2011

2 Oct-2011

II.5.03.t Disposable filter infuser 1 6 6 Sep-2010

II.5.04 Urine drainage bag eith penile sheath set 1 2 2

II.5.05.a Syringes sterile, 2 ml, disposable 1 15050 Mar-2014

50 Mar-2011

II.5.05.b Syringes sterile, 5 ml disposable 1 5020 Feb-2011

II.5.05.c Needles sc 16 X 0.5 mm, sterile, for II.5.05.a/b 1 505+5 Dec-2011/Jun-2012

20 Mar-2013

II.5.05.d Needles sc 40 X 0.8 mm, sterile, for II.5.05.a/b 1 200

50 Mar-2011

50 Sep-2013

25 Jun-2013

II.5.05.e IV infusion cannula 1.2, sterile, to be used with iv set 1 1010 Dec-2013

3 Oct-2010

II.5.05.f Infusion set with cannula 1 10 10 Dec-2014

II.5.05.g Tourniquet 1 2 2

II.5.06 Catheter "Thieman", Ch. 18 1 21 Oct-2010

2 Nov-2010

Page 10: Med.inventory 06.2010

Page 10 of 13 Encl. 45 Rev. 3

Pos Description Storage Stock on board Expiry datePackage unitpcs/ml/gs

Recommendedquantities for

up to 15 persons

New supply:only decided

by pharmacist

II.5.07 Catheter lubricant 1 2 2 Feb-2010

Page 11: Med.inventory 06.2010

Page 11 of 13 Encl. 45 Rev. 3

Pos Description Storage Stock on board Expiry datePackage unitpcs/ml/gs

Recommendedquantities for

up to 15 persons

New supply:only decided

by pharmacist

II.5.08 Basin, emesis kidney-shape, stainless-steel 1 2 2

II.5.08 Basin, emesis kidney-shape, disposable 1 10 10

General medical equipmentII.6.01 Bedpan 1 1 1

II.6.02 Hot water bottle, rubber 1 1 2

II.6.03 Urinal, male 1 1 1

II.6.04 Cold/Hot pack 1 1 2

II.6.06 Thermo-isolation foil 1 1 3

Immobilisation and setting equipmentII.7.01 Splint, finger aluminium 1 2 2

II.7.02 Splint, 70 cm 1 6 6

II.7.03 Inflatable splint, set, assorti 1 1 1

II.7.04 Splint, type "Thomas" 1 1 1

II.7.05 Neck collar "Stifneck" 1 2 3

II.7.06 Vacuum matress 1 1 1

II.7.07 Stretcher, marine type 1 1 1

Desinfection, disinsectization and ProphylaxisII.8.01 Drinking water disinfectant 2500 1 2500 Jun-2011 2/M cabin

II.8.02 Insecticide spray 400 5 2

II.8.03 Insecticide powder, 2 X 20 g 250 2 5

II.8.04 Insect repellent 50 302500 Aug-2013

300 Jul-2011

MiscellaneousII.9.01.b Mortuary transfer bag 1 2 2

II.9.03 Sheath, rubber (condoms) 1 5030 Jan-2011

10 Nov-2012

II.9.04 Lid-Waste-bin with pedal 1 1 1

Disposable bag for Waste-bin, 20 pcs. 20 2 2

II.9.05 Microscope slides 1 12 22

II.9.06 Applicator, wooden with cotton wool. 50 120

II.9.07 Flexible straws 20

II.9.10 Medical Guide 1 1 1

II.9.11 Handbook IMDG Code 2008 Ed. Vol.1 & Vol.2, incl supplement 2008 Ed. 1 1 1 Crg. Office

II.9.13 First aid kit for lifeboats according to Dutch regulation, complete 1 22 Oct-20112 Oct-2011

Page 12: Med.inventory 06.2010

ECORD CONCERNING THE DESTRUCTION OF CONTROLLEDSUBSTANCES

The following controlled substances were destroyed in such a way that reuse in any form whatsoever is impossible:

Name and quantity:

Vessel’s name:WESTERHAVEN Flag: The Netherlands Call sign: P C I D

Reasons for destruction: 1) expired2) not required any more3) exchanged

Date and place of destruction:

Destruction confirmed by:

Arie Bijl Officer-in-charge(as representative of theowner) Name and signature

1. witness 2. witnessName and signature Name and signature

Page 13: Med.inventory 06.2010

ECORD CONCERNING THE DESTRUCTION OF CONTROLLEDSUBSTANCES

The following controlled substances were destroyed in such a way that reuse in any form whatsoever is impossible:

Name and quantity:

Vessel’s name:WESTERHAVEN Flag: The Netherlands Call sign: P C I D

Reasons for destruction: 1) expired2) not required any more3) exchanged

Date and place of destruction:

Destruction confirmed by:

Arie Bijl Officer-in-charge(as representative of theowner) Name and signature

1. witness 2. witnessName and signature Name and signature