SURVEY REPORT ON CARGO GEAR Type: Initial Annual Occasional Name of Ship I.M.O No. Flag Call Sign Class Number G.R.T Type of Ship Hull Material Survey Items Exa. Meas. Test Remarks Derricks and Union Purchase Masts and derrick posts Cross trees Derrick boom Marking booms Built-in sheave Boom head guy (schooner guy) Derrick gooseneck fitting Derrick heel assembly Span (topping) rope Rope sockets Thimbles Derrick span cargo block Boom eye for span ropes Mast head span block Mast head span eye fitting Derrick heel span lead block Shackles Rings Rigging screws Delta (triangular) plate Span chain Connection to deck plate (shackle) Deck plate Topping winch Cargo runner Cargo runner guide Rope sockets Thimbles Boom eye for cargo runner Derrick head cargo block Mast head cargo runner lead block Lower cargo purchase block Derrick heel cargo runner lead block Swivel Cargo hook Shackles GUARDIAN BUREAU OF SHIPPING LLC PAGE 1 OF 3 FORM 9010/SRCG/GBS/DEL/99 Rings Rigging screws Cargo winch Slewing guy pendants (rope) Derrick slewing guy tackle rope Rope sockets Thimbles Slewing guy tackle Upper slewing guy block Lower slewing guy block (or lead blocks) Shackles Rings Rigging screws Slewing guy deck eye plate Slewing winch Preventer safety catch Preventer guy (stay ropes) Rope sockets Thimbles Preventer guy chain Preventer guy eye plate Shackles Rings Rigging screws Preventer guy winch Cranes Mast Jib-boom Crane frame Crane substructures Roof crane Jib heel pins Slewing rings for cranes Blocks Ropes Shackles Rings Hooks Rope drums Cargo lifts and ramps Wire ropes Sprockets Chains Sheaves Shackles Operating locks (safety guards) Guide rollers Axle pins Slewing bearings Main pivots GUARDIAN BUREAU OF SHIPPING LLC PAGE 2 OF 3 FORM 9010/SRCG/GBS/DEL/99 Rope drums Hydraulic cylinders Winches Passenger lifts Wire ropes Chains Sheaves Sprockets Guide rollers Axle pins Bearings Lift trunk Landing doors Guides Over-running devices and brakes Safety gear Safety equipment (hatches, ladders etc.) Hydraulic cylinders Winches Annual survey have been carried out/not been carried out on the parts which can be dismantled by owners. Load tests of Derricks and Cranes. No. of Derricks or Cranes 1 2 3 4 5 6 7 8 9 10 Proof load applied Safe working load Union Proof load applied Purchase Safe working load Repairs and replacements carried out during the survey. REMARKS: Changes and additional information to the Register. Place: Date: The Surveyor: Signature: GUARDIAN BUREAU OF SHIPPING LLC PAGE 3 OF 3 FORM 9010/SRCG/GBS/DEL/99 .