| 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:
............................................
|