ATT_3_DD250-1_BARGE_MATERIAL_INSPECTION_AND_RECEIVING_REPORT.pdf

TANKER/BARGE MATERIAL INSPECTION

AND RECEIVING REPORT

Form Approved OMB No. 0704-0248

PLEASE DO NOT RETURN YOUR COMPLETED FORM TO THE ABOVE ORGANIZATION.

SEND THIS FORM IN ACCORDANCE WITH THE INSTRUCTIONS CONTAINED IN THE DFARS, APPENDIX F-401.

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 Address) 12. B/L NUMBER

13. REQN. OR REQUEST NO. 14. CARGO NUMBER

16. DRAFT ARRIVAL15. VESSEL

FORE AFT

17. DRAFT SAILING

FORE AFT

18. PREVIOUS TWO CARGOES

FIRST LAST

19. PRIOR INSPECTION

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)

GALLONS (Net)

TONS (Long)

26. STATEMENT OF QUALITY

TESTS SPECIFICATION LIMITS TEST RESULTS

27. TIME STATEMENT DATE TIME

NOTICE OF READINESS TO LOAD DISCHARGE

VESSEL ARRIVED IN ROADS

MOORED ALONGSIDE

STARTED BALLAST DISCHARGE

FINISHED BALLAST DISCHARGE

INSPECTED AND READY TO LOAD DISCHARGE

CARGO HOSES CONNECTED

COMMENCED LOADING DISCHARGE

STOPPED LOADING DISCHARGING

RESUMED LOADING DISCHARGING

FINISHED LOADING DISCHARGING

CARGO HOSES REMOVED

VESSEL RELEASED BY INSPECTOR

COMMENCED BUNKERING

FINISHED BUNKERING

VESSEL LEFT BERTH (Actual/Estimated)

28. REMARKS (Note in detail cause of delays such as repairs, breakdown, slow operation, stoppages, etc.)

29. COMPANY OR RECEIVING TERMINAL

(Signature)

30. I CERTIFY THAT THE CARGO WAS INSPECTED, ACCEPTED AND

LOADED/DISCHARGED AS INDICATED HEREON.

(Date) (Signature of Authorized Government Representative)

31. I HEREBY CERTIFY THAT THIS TIME STATEMENT IS

CORRECT.

(Master or Agent)

DD Form 250-1, NOV 92 Previous edition may be used.

The public reporting burden for this collection of information is estimated to average 30 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 the burden, to the Department of Defense, Executive Services Directorate (0704-0248). Respondents should be aware that notwithstanding any other provision of law, no person shall be subject to any penalty for failing to comply with a collection of information if it does not display a currently valid OMB control number.