Form CG-4260 Application and Permit to Handle Hazardous Materials

APPLICATION AND PERMIT TO HANDLE
HAZARDOUS MATERIALS

U.S. DEPA5T0(17 OF
HOMELAND SECURITY
U.S. COAST GUARD
CG-42605HY

(See Instructions on Page 2.)

TO
CAPTAIN OF THE PORT
U.S. COAST GUARD

Form Approved
OMB No. 1625-0005
Exp. Date xx/xx/xxxx

FROM (Name, Business address and zip code)

HAZARD CLASS
OR DIVISION

CARGO BY PROPER SHIPPING NAME

STOWAGE
(Vessel Only)

WEIGHT
(Net Tons)

TOTAL
VESSEL OR BARGE

0

WATERFRONT FACILITY

NAME AND
LOCATION
NAME, ADDRESS
AND ZIP CODE
OF OWNER
NAME, ADDRESS
AND ZIP CODE
OF AGENT OR
CHARTERER
DATE(S) AND
TIME(S) OF
OPERATION
I UNDERSTAND and will comply with current safety laws, rules and regulations of the United States, the State,
County, City and Port Authority while handling hazardous materials. (See Page 2.)
DATE

TITLE (Authorized Company
Representative)

SIGNATURE

PERMIT
THE ABOVE REQUEST IS:
APPROVED WITH THE FOLLOWING CONDITIONS

APPROVED
EXCEPTIONS/CONDITIONS

DATE

SIGNATURE (Captain of the Port, U.S. Coast Guard)
INSPECTION (VESSEL LOADING ONLY)
The stowage of the cargo listed above has been inspected and accepted as satisfactory.

DATE

SIGNATURE AND POSITION (Master/Mate/Person in Charge of Vessel)

PREVIOUS EDITION IS OBSOLETE

VESSEL COPY

DISAPPROVED

APPLICATION AND PERMIT TO HANDLE
HA=ARDOUS0$T(RIALS

U.S. DEP$R7M(172)
HOMELAND SECURITY
U.S. COAST GUARD
C*5HY6-04)

(See Instrructions on Page 2.)

TO
CAPTAIN OF THE PORT
U.S. COAST GUARD

Form$pprRYed
OMB No.1625-0005

FROM (Name, Business address and zip code)

HAZARD CLASS
OR DIVISION

CARGO BY PROPER SHIPPING NAME

STOWAGE
(Vessel Only)

WEIGHT
(Net Tons)

TOTAL
VESSEL OR BARGE

0

WATERFRONT FACILITY

NAME AND
LOCATION
NAME, ADDRESS
AND ZIP CODE
OF OWNER
NAME, ADDRESS
AND ZIP CODE
OF AGENT OR
CHARTERER
DATE(S) AND
TIME(S) OF
OPERATION
I UNDERSTAND and will comply with current safety laws, rules and regulations of the United States, the State,
County, City and Port Authority while handling hazardous materials. (See Page 2.)
DATE

TITLE (Authorized Company
Representative)

SIGNATURE

PERMIT
THE ABOVE REQUEST IS:
APPROVED

APPROVED WITH THE FOLLOWING CONDITIONS

DISAPPROVED

EXCEPTIONS/CONDITIONS

DATE

SIGNATURE (Captain of the Port, U.S. Coast Guard)
INSPECTION (VESSEL LOADING ONLY)
The stowage of the cargo listed above has been inspected and accepted as satisfactory.

DATE

SIGNATURE AND POSITION (Master/Mate/Person in Charge of Vessel)

PREVIOUS EDITION IS OBSOLETE

UNIT COPY

Reset

Page2ofCG-426(RHv 6-04)

INSTRUCTIONS

Submit original and one copy to the Captain of the Port having jurisdiction over the load/discharge location
(See 33 CFR Part 3)
This application and permit is required by the following regulations:
49 CFR 176.100 (Military & Commercial Explosives, Division 1.1 and 1.2)
49 CFR 176.415 (Blasting Agents and Ammonium Nitrates)
33 CFR 126.17 (Military & Commercial Explosives, Division 1.1 and 1.2)
Supplemental information required by the above regulations must be appended to this application.
"Proper Shipping Name" means the name of the cargo as given in 49 CFR 172.101. The "correct technical name" as given in the
International Maritime Dangerous Goods Code published by IMO may be used as prescribed by regulation.

CONDITIONS

This permit is subject to the following conditions:
a.

The limits as to maximum quantity, isolation, and remoteness established by local, municipal, territorial or state
authorities having jurisdiction (or the quantity of this permit) shall not be exceeded by this operation. This permit does not
authorize the violation of any applicable state or municipal law, ordinance, regulation or permit.

b.

The Captain of the Port shall be notified immediately of any changes in quantity, times, dates, or of any matters that might
affect the safe handling or transportation of the cargo covered by this permit.

c.

All applicable laws and regulations, unless waived by the Captain of the Port, and all directions or orders of the Captain of
the Port or his authorized representative, shall be complied with.

An agency may not conduct or sponsor, and a person is not required to respond to a collection of information
unless it displays a valid OMB number.
The Coast Guard estimates that the average burden for this report is 1 hour. You may submit any comments
concerning the accuracy of this burden estimate or any suggestion for reducing the burden to: Commandant
(G-MOC), U.S. Coast Guard, Washginton, DC 20593, Project (1625-0007).