CG-6056 International Air Pollution Prevention Certificate

OMB APPROVAL 1625-0041

INTERNATIONAL AIR POLLUTION PREVENTION CERTIFICATE
Issued under the provisions of the Protocol of 1997 to amend the International Convention for the
Prevention of Pollution from Ships, 1973, as modified of the Protocol of 1978 related 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

Type of ship:

Distinctive
number or
letters

IMO
number

Port of registry

Gross tonnage

tanker
ship other than a tanker

THIS IS TO CERTIFY:
1. That the ship has been surveyed in accordance with Regulation 5 of Annex VI of
the Convention; and
2. That the survey shows that the equipment, systems, fittings, arrangements and
materials fully comply with the applicable requirements of Annex VI of the
Convention.
This Certificate is valid until …………………… subject to surveys in accordance with
Regulation 5 of Annex VI of the Convention.
Issued at …………………………………………………………………….……………..
…………….

-------------------------------------------------------------

Date of Issue

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

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a valid OMB control number. The Coast Guard estimates that the average burden for this report is 10 minutes. You may
submit comments concerning the accuracy of this burden estimate or any suggestions for reducing the burden to COMDT (GMOC), 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-6056 (11/2004)

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Vessel Name:

Date Issued:

INTERNATIONAL AIR POLLUTION PREVENTION CERTIFICATE

ENDORSEMENT FOR ANNUAL AND INTERMEDIATE SURVEYS
THIS IS TO CERTIFY that based upon a survey required by regulation 5 of Annex VI of the
Convention, the ship was found to comply with the relevant provisions of the Convention:

Annual Survey:

Annual*/Intermediate Survey:

Annual*/Intermediate Survey:

Annual Survey:

Signed:

______________________

Place:

______________________

Date:

______________________

Signed: ______________________
Place:

______________________

Date:

______________________

Signed:

______________________

Place:

______________________

Date:

______________________

Signed:

______________________

Place:

______________________

Date:

______________________

* Delete as Appropriate

U.S. DEPT. OF HOMELAND SECURITY, USCG, CG-6056 (11/2004)

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