CG-4260 (01/18) Application and Permit to Handle Hazardous Materials

DEPARTMENT OF HOMELAND SECURITY

U.S. Coast Guard
APPLICATION AND PERMIT TO HANDLE HAZARDOUS MATERIALS

Form Approved
OMB No. 1625-0005

(See instructions on Page 2)
1. TO:

2. FROM: (Name, Business address and postal code)

CAPTAIN OF THE PORT
U.S. COAST GUARD

3. CARGO BY UN NUMBER, PROPER SHIPPING NAME AND EX NUMBER
(if included)

7.

ONLOAD

4. HAZARD CLASS, DIVISION AND 5. STOWAGE LOCATION 6. WEIGHT
COMPATIBILITY GROUP
(Vessel Only)
(Net Pounds)

OFFLOAD

8. TOTAL FOR NET EXPLOSIVE WEIGHT:
VESSEL OR BARGE

WATERFRONT FACILITY

9. NAME, VESSEL IMO
OR ID#, LOCATION,
POINT OF CONTACT
(name and phone #)
10. NAME, ADDRESS,
AND POSTAL CODE
OF OWNER

11. NAME, ADDRESS,
AND POSTAL CODE
OF LESSOR OR
CHARTERER
12. 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.)
13. DATE

15. APPLICANT'S SIGNATURE

14. TITLE

PERMIT (COAST GUARD USE ONLY)
The above request is:

Approved

Approved with the following conditions

Disapproved

EXCEPTIONS/CONDITIONS

DATE

SIGNATURE: (Captain of the Port, U.S. Coast Guard)

VESSEL/FACILITY REPRESENTATIVE ACKNOWLEDGMENT
I have read and understand the conditions of this permit.
DATE

DATE

CG-4260 (01/18)

VESSEL RESPONSIBLE PERSON SIGNATURE:

SIGNATURE:

FACILITY REPRESENTATIVE
POSITION:

Reset

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INSTRUCTIONS
Submit original and one copy to the Captain of the Port having jurisdiction
over the load/discharge location (See 33 CFR § 3).
Submit application to the Captain of the Port having jurisdiction over the load/discharge location (see 33CFR § 3).
This application and permit is required by the following regulations:
49 CFR § 176.100 (Military and Commercial Explosives, Division 1.1 and 1.2)
49 CFR § 176.415 (Division 1.5, ammonium nitrates, and certain ammonium nitrate fertilizers)
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.
Block 1 - Enter the Name of the particular Captain of the Port Zone where the Explosives will be handled, loaded or unloaded as described in
33 CFR § 3.
Block 2 - Enter the Name of the Agent, Shipper, Charterer or Owner submitting the Application and Permit to Handle Hazardous Materials.
Block 3 - Enter the Cargo Identification information by UN Number, Proper Shipping Name and Explosive (EX) Approval Number (if EX Approval
Number is required). “Proper Shipping Name” means the name of the cargo as given in 49 CFR § 172.101 Hazardous Materials Table. The
“correct technical name” as given in the International Maritime Dangerous Goods Code published by IMO may be used as prescribed by
regulation.
Block 4 - Enter the Hazard Class information including Class, Division and Compatibility Group Letter.
Block 5 - Enter the Stowage Location on the Vessel, either On-deck or Under-deck.
Block 6 - Enter the Net Weight of Explosives in Pounds.
(To convert Kilograms to Pound is: Kg 2.205 = Pounds)
Block 7 - Check the appropriate box to indicate if cargo is being loaded on a vessel or offloaded from a vessel.
Block 8 - The total New Explosive Weight (N.E.W.) in the shipment in pounds will automatically populate with the sum of the weight(s) entered into
Block 6.
Block 9 - Enter the Name and ID or IMO Number for the Vessel or Barge, and the Name and Location of the Facility or Anchorage.
Block 10 - Enter the name, mailing address and Postal code for the Vessel Owner and the Facility Owner.
Block 11 - Enter the name, mailing address, Postal code and Phone Number for the Lessor or Charterer.
Block 12 - Enter the proposed Date and Time for the Operation (Local Time).
Block 13 - Enter the date the Application and Permit to Handle Hazardous Materials is submitted.
Block 14 - Enter the title of the Individual submitting the Application and Permit to Handle Hazardous Materials.
Block 15 - Signature (Electronic or Physical) of the Individual submitting the Application and Permit to Handle Hazardous Materials
Instructions for the Captain of the Port: Select if the request is Approved, Approved with the Following Conditions, or Disapproved. If approved with
conditions, enter those in the Exceptions/Conditions box. If Exceptions/Conditions exceed the space provided on the permit, write "See attached for
Exceptions/Conditions. The attached Exceptions/Conditions must accompany the permit at all times." in this space.

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.
Privacy Act Statement
Authority:

33 U.S.C. 1225; 49 U.S.C. 5101-5108; 33 C.F.R. § 126.19; 49 C.F.R. § 176.100; and 49 C.F.R. § 176.415.

Purpose:

To determine if hazardous materials may be loaded or unloaded from a vessel or barge to a waterfront facility.

Routine Uses: Authorized Coast Guard personnel will use this information to adjudicate Permit to Handle Hazardous Materials applications. Any external
disclosures of data within this record will be made in accordance with DHS/USCG-013, Marine Information for Safety and Law
Enforcement System of Records, 74 Federal Register 30305 (June 25, 2009).
Disclosure:

Furnishing this information is mandatory. Failure to furnish this information may delay/prevent the issuance of the Permit to Handle
Hazardous Materials or result in punitive action.

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 (CG-FAC), U.S. Coast Guard Stop 7501, 2703 Martin Luther King Jr Ave, SE, Washington, D.C.
20593-7501.
CG-4260 (01/18)

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