Form CG-5352 International Convention for the Preventin

OMB APPROVAL 1625-0041

INTERNATIONAL OIL POLLUTION PREVENTION CERTIFICATE
(Note: This Certificate shall be supplemented by a Record of Construction and Equipment)
Issued under the provisions of the

INTERNATIONAL CONVENTION FOR THE PREVENTION
OF POLLUTION FROM SHIPS, 1973
as modified by the Protocol of 1978, relating thereto,
(hereinafter referred to as "the Convention")
under the authority of the Government of

THE UNITED STATES OF AMERICA
by the UNITED STATES COAST GUARD
Name of Ship

Distinctive Numbers or
Letters

Port of Registry

Gross Tonnage

Deadweight of ship
(tons)+

IMO Number ++

Type of ship:
Oil Tanker (Form B Supplement attached)
Ship other than an oil tanker with cargo tanks coming under regulation 2.2 of Annex I of the
Convention (Form B Supplement attached)
Ship other than any of the above (Form A Supplement attached)
THIS IS TO CERTIFY:
1.

That the ship has been surveyed in accordance with the requirements of regulation 6
of Annex I on the Convention; and

2.

That the survey shows that the structure, equipment, systems, fittings, arrangement
and material of the ship and the condition thereof are in all respects satisfactory and
that the ship complies with the applicable requirements of Annex I of the Convention.

This certificate is valid until*: _______________________________________________
subject to surveys in accordance with regulation 6 of Annex I of the Convention.
Issued at: _________________________________________________________________
Place of issue

Date of Issue
+
++
*

Officer in Charge, Marine Inspection, U.S. Coast Guard

For oil tankers
Refer to the IMO Ship Identification Number Scheme adopted by the Organization by resoltion A.600(15).
Insert the date of expiry as specified by the Administration in accordance with regulation 10.1 of Annex I of the Convention. The day and the month of this
day correspond to the anniversary date as defined in regulation 1.27 of Annex I of the Convention, unless amended in accordance with regulation 10.8 of
Annex I of the Convention.

The Coast Guard estimates that the average burden for this report is 20 minutes. You may submit any comments concerning the accuracy of this burden estimate or
any suggestions for reducing the burden to: Commandant (CG-3PCV), U.S. Coast Guard, Washington, DC 20593-0001 or Office of Management and Budget,
Paperwork Reduction Project (1625-0041), Washington DC 20503.
U.S. Dept. of Homeland Security, USCG, CG-5352 (Rev. 01-07)
PREVIOUS EDITIONS ARE OBSOLETE

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INTERNATIONAL OIL POLLUTION PREVENTION CERTIFICATE

ENDORSEMENT FOR ANNUAL AND INTERMEDIATE SURVEYS
THIS IS TO CERTIFY that at a survey required by regulation 6 of Annex I of the Convention the ship
was found to comply with the relevant provisions of the Convention.

Annual Survey:

Signed:
Place:
Date:

Annual*/Intermediate Survey:

Signed:
Place:
Date:

Annual*/Intermediate Survey:

Signed:
Place:
Date:

Annual Survey:

Signed:
Place:
Date:

* Delete as appropriate

U.S. Dept. of Homeland Security, USCG, CG-5352 (Rev. 01-07)

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ANNUAL/INTERMEDIATE SURVEY IN ACCORDANCE WITH
REGULATION 10.8.3
THIS IS TO CERTIFY that, at an annual/intermediate* survey in accordance with regulation 10.8.3
of Annex I of the Convention, the ship was found to comply with the relevant provisions of the
Convention:
Signed:
(Signature of duly authorized official)
Place:
Date:

ENDORSEMENT TO EXTEND THE CERTIFICATE IF VALID FOR LESS THAN
5 YEARS WHERE REGULATION 10.3 APPLIES
This ship complies with the relevant provisions of the Convention, and this Certificate shall, in
accordance with regulation 10.3 of Annex I of the Convention, be accepted as valid until
Signed:
(Signature of duly authorized official)
Place:
Date:

ENDORSEMENT WHERE THE RENEWAL SURVEY HAS BEEN COMPLETED
AND REGULATION 10.4 APPLIES
The ship complies with the relevant provisions of the Convention and this Certificate shall, in
accordance with regulation 10.4 of Annex I of the Convention, be accepted as valid until
Signed:
(Signature of duly authorized official)
Place:
Date:

*

Delete as appropriate.

U.S. Dept. of Homeland Security, USCG, CG-5352 (Rev. 01-07)

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ENDORSEMENT TO EXTEND THE VALIDITY OF THE CERTIFICATE UNTIL
REACHING THE PORT OF SURVEY OR FOR A PERIOD OF GRACE WHERE
REGULATION 10.5 OR 10.6 APPLIES

This Certificate shall, in accordance with regulation 10.5 or 10.6* of Annex I of the Convention, be
accepted as valid until
Signed:
(Signature of duly authorized official)
Place:
Date:

ENDORSEMENT FOR ADVANCEMENT OF ANNIVERSARY DATE WHERE
REGULATION 10.8 APPLIES
In accordance with regulation 10.8 of Annex I of the Convention the new anniversary date is
Signed:
(Signature of duly authorized official)
Place:
Date:

In accordance with regulation 10.8 of Annex I of the Convention the new anniversary date is

Signed:
(Signature of duly authorized official)
Place:
Date:

*

Delete as appropriate.

U.S. Dept. of Homeland Security, USCG, CG-5352 (Rev. 01-07)

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