Ship’s
name:
...................................................................................................................
|
IMO
number:
..................................................................................................................
|
Class/Administration identity number:
...............................................................................
|
Port
of registry:
...............................................................................................................
|
Gross
tonnage:
................................................................................................................
|
Deadweight:
....................................................................................................................
|
Date
of build:
..................................................................................................................
|
Classification society:
.......................................................................................................
|
|
|
Name
of company performing thickness measurement:
....................................................
|
Thickness measurement company certified by:
.................................................................
|
Certificate number:
..............................................................................................................
|
Certificate valid from:
.................................
|
to
................................................................
|
Place
of measurement:
.......................................................................................................
|
First
date of measurement:
.................................................................................................
|
Last
date of measurement:
.................................................................................................
|
Renewal survey/intermediate surveyfootnote due:
..........................................................................
|
Details of measurement equipment:
...................................................................................
|
Qualification of operator:
......................................................................................................
|
|
|
Report number:
..........................................
|
consisting of
......................... pages.
|
Name of operator:
......................................
|
Name of surveyor:
.....................................
|
Signature of operator:
................................
|
Signature of surveyor:
................................
|
|
|
Company official stamp:
............................
|
Administration:
...........................................
|
|
Official stamp:
............................................
|