We ask you to approve and take off from M/S _______________ the following useless materials (inventory, spare parts, _______________ ) as scrap:

Date _______________________

No.	Description	Unit	Quantity	Reg'ed in		Wear	Weight
				Page	item	in %

Submitted Confirmed Approved

_________________ _________________ __________________

Chief of Dept. Master of M/S Superintendent

Note: To be completed when necessary and filed in both office's file and ship's file.

To retain for 5 years.

Issue date: 03.11.2003/Rev. 00 PBO-TD05-F04 Page: 1/1

LIST OF SCRAP RETURNED ASHORE

QSMS PBO-TD05-F04 Rev. No.00

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