BỘ NÔNG NGHIỆP VÀ PHÁT TRIỂN NÔNG THÔN
CỤC QUẢN LÝ CHẤT LƯỢNG
NÔNG LÂM SẢN VÀ THUỶ SẢN
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CỘNG HÒA XÃ HỘI CHỦ NGHĨA VIỆT NAM
Độc lập - Tự do - Hạnh phúc
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Số: 1173/QLCL-CL1
V/v mẫu chứng thư mới cho các lô hàng thủy sản xuất khẩu vào Indonesia

Hà Nội, ngày 09 tháng 9 năm 2021

Kính gửi:

- Các doanh nghiệp chế biến thủy sản xuất khẩu vào Indonesia;
- Các Trung tâm chất lượng nông lâm thủy sản vùng.

Nơi nhận:
- Như trên;
- PCT Lê Bá Anh (để biết);
- Chi cục Trung bộ, Nam bộ;
- Hiệp hội VASEP;
- Lưu: VT, CL1.

CỤC TRƯỞNG




Nguyễn Như Tiệp

No

Common name/ Nama umum

Scientific name/ Nama ilmiah

HS code/ Kode HS

Quantity/ Jumlah

Unit

1

TOTAL

1. Consignor/ Pengirim barang

Name/ Nama:

Address/ Alamat:

2. Competent authority/ Otoritas kompeten

3. Consignee/ Penerima barang

Name/ Nama:

Address/ Alamat:

4. □ Aquaculture establishment/ unit Pembudidayaan Ikan

Name/ Nama :

Address (detailed)/ Alamat lengkap:

□ Fish processin establishment/ Unit Pengelolaan Ikan           □ Others/ Lainnya

Establishment ID Number/ No Registrasi:

5. Country and region of origin/ Negara dan daerah asal:

6. Source/ Sumber:

□ farm-raised/ budidaya    □ wild-caught/ tangkap

7. Port of shipment/ pelabuhan pengeluaran:

8. Means of transport/ Alat transportasi:

□ Aeroplane/ Angkatan udara        □ Ship/ Angkatan laut

□ Road vehicle/ Angkatan darat

10. Temperature of the commodity/ Temperatur komoditas:

□ ambient/ suhu ruang          □ frozen/ beku          □ chilled/ dingin

9. Description of commodity/ Deskripsi komoditas:

11. Commodities intended for uses as/Komoditas diperuntukkan sebagai:

□ Human consumption/ Konsumsi manusia

□ Culture/ breeding (broodstock, eggs, gametes)/ Budidaya

□ Trade/ diperdagangkan

□ Research & Investigation/ Penelitian dan pemeriksaan

□ Fish feed/baits/ Pakan/ umpan pancing

□ Exhibition/ pameran

□ Other/ lainnya

12. Total number of package, associated batch numbers and number of packages per batch/ Jumlah kemasan total terkait nomor batch dan kemasan per batch

*(information on batch see attachment if insufficient/informasi tentang batch dapat dibuat pada lampiran jika kolom tidak cukup )

13. Type of packaging/ Jenis kemasan:

14. Total quantity(kg)/ Jumlah total (kg):

15. Identification of container/ seal number

Identifikasi kontainer/ nomor segel:

16. Port of destination/ Pelabuhan tujuan:

17. Identification of transport/ Identitas alat transport

Name of vessel/nama kapal:

Voyage number/nomor penerbangan:

18. Date of departure/ Tanggal pengiriman:

19. Testing laboratory/ Laboratorium penguji:

Address/ Alamat:

Approving officer/ Penanggungjawab laboratorium:

Test result number/ Nomor laporan hasil uji:

Signature/ tanda tangan

Attestation

The undersigned certifying official certifies that product(s) / Pejabat penandatangan sertifikat di bawah ini menyatakan bahwa produk:

□ Finfish/ Ikan bersirip       □ Mollusca/ Moluska      □ Crustacea/ Krustasea     □ Fishery product/ Produk perikanan      □ Others/ Lainnya

Others described above satisfy(s) the following requiremts / yang diuraikan di atas memenuhi persyaratan berikut:

□  a. The Product from each batch/Commodity from population *) described above have been processed, inspected and graded in (an) establishment(s) that has been approved by and under control of the Competent Authority/ Produk tersebut di atas telah diproses, diinspeksi dan dinilai dalam kondisi yang telah disetujui oleh dan di bawah Otoritas Kompeten

□  b. Have been handled, prepared or processed, identified, stored and transported under a competent HACCP and sanitary programme consistently implemented and in accordance with the requirements laid down in Codex Code of Practice for Fish and Fishery Products (CAC/RCP 52-2003)/ telah ditangani, disiapkan atau diproses, diidentifikasi, disimpan dan ditransportasikan sesuai persyaratan sanitasi dan HACCP yang diterapkan secara konsisten dans sesuai dengan persyaratan yang ditetapkan Cdex Code of Practice for Fish and Fishery Product (CAC/RCP 52-2003)

□  c. The Product from each bacth/Commodity from population *) has been found to be free of disease based on sampling and testing method recognized by the World Organisation for Animal Health (OIE) for demonstrating absence of disease and inspected according to the appropriate procedures and subsequently found, at the time of inspection:/Produk/dari setiap batch pasca pengolahan bebas dari penyakit berdasarkan pengambilan sampel dan metode pengujian yang diakui oleh World Organisation for Animal (OIE) dan pada saat pemeriksaan:

□ - For crustacean declared free from AHPND, IHHNV, YHV, TSV, WSSV, WTD, IMNV, LsNV and Crayfish plague.
(untuk jenis krustasea bebas dari AHPND, IHHNV, YHV, TSV, WSSV, WTD, IMNV, LsNV dan Crayfish plague)

□ - For cyprinidae declared free from SVC, KHV, RSD, and Furunculosis
(untuk jenis Corp bebas dari SVC, KHV, RSD, and Furunculosis)

□ - For tilapia or orechromis declared free from TiLV, IPNV, RSIVD, VNN, RSD, ESC and Furunculosis.
(untuk jenis Tilapia atau Oreochromis bebas dari TiLV, IPNV, RSIVD, VNN, RSD, ESC dan Furunculoasis)

□ - For catfish declared free from CCVD, VHSV, RSD, Furunculosis, ESC and EUS.
(untuk jenis Catfish bebas dari CCVD, VHSV, RSD, Furunculosis, ESC dan EUS)

□ - For other fish species, declared free in accordance with the list of fish diseases of OIE relevant to the susceptible species.
(untuk jenis ikan lainnya, mengikuti daftar penyakit hewan akuatik OIE yang relevan dengan spesies rentan tersebut)

□ - To show no visible/ clinical signs of disease/
(tidak menunjukan gejala penyakit secara visual/klinis:

□ - The fish must be in shipping containers, holding units and/or conveyan that are either new cleaned and disinfected. The shipping containers and/or holding units must prevent release of the shipping contens (eg. Water or animals) while en route.
(ikan harus dikemas dalam container pengiriman, kemasan, dan/atau alat angkut yang baru atau dibersihkan dan didesinfeksi.
Wadah pengiriman dan / atau kemasan atau alat angkut harus mencegah pelepasan isi pengiriman (mis. Air atau Ikan) saat sedang dalam perjalanan.

□ d. For non edible product have been handled, prepared or processed, stored, transported based on biosecurity principles/
Produk non pangan telah ditangani, disiapkan atau diproses, disimpan, ditransportasikan berdasarkan prinsip biosekuriti

□ e. ….

Additional information/Informasi tambahan

CERTIFIED DETAILS/ Detail penerbit sertifikat

Issued at/ Dikeluarkan      On/ di

Stamp/ Stempel

Signature/ Tanda tangan

(Name of Official or Inspector/ Nama petugas atau Inspektur)

Name/ Nama:

Position/ Jabatan:

Issued at/ Lokasi:

Phone/ Telepone:

Fax/ Faksimili:

Email/ Surat elektronik:

Addres/ Alamat: