CG-5148C Certificate of Fitness

Form Approved
OMB No. 1625-0094

Certificate of Fitness
Issued under the provision of the Guidelines for the Transport and Handling of Limited Amounts of
Hazardous and Noxious Liquid Substances in Bulk on Offshore Support Vessels (resolution
A.673(16), as amended by resolutions MSC.236(82) and MEPC.158(55)) under the authority of the
Government of:

THE UNITED STATES OF AMERICA
by the
UNITED STATES COAST GUARD

Particulars of Ship
Name of Ship

Distinctive
Numbers or Letters

Port of Registry

Gross
Tonnage

IMO Number*

Date on which keel was laid or on which the vessel was at a similar stage of construction or, (in the case of a converted
vessel) date on which conversion for the carriage of bulk liquids subject to these Guidelines was commenced:
_____________________________________________
The vessel also complies fully with the following amendments to the Guidelines:
__________________________________________________________________________________________________
__________________________________________________________________________________________________

The vessel is exempted from compliance with the following provision of the Guidelines:
__________________________________________________________________________________________________
__________________________________________________________________________________________________

An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it
displays a valid OMB control number.
The Coast Guard estimates that the average burden for this report is 30 minutes. You may submit any comments
concerning the accuracy of this burden estimate or any suggestions for reducing the burden to: Commandant (CG543), U.S. Coast Guard, 2100 St., SW, Washington D.C. 20593-0001 or Office of Management and Budget,
Paperwork Reduction Project (1625-0094), Washington, DC 20503.

* In accordance with the IMO ship identification number scheme. Adopted by the Organization by resolution A.600 (15).

U.S. DEPT. OF HOMELAND SECURITY, USCG, CG-5148C, (Rev. 04-09)

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THIS IS TO CERTIFY:
1

.1

That the ship has been surveyed in accordance with the provisions of 1.5 of the Guidelines;

.2

that the survey showed that the construction and equipment of the ship complied with the relevant provision(s)
of the Guidelines applicable to
ships;

2

That the vessel has been provided with a Manual in accordance with Appendix 4 of Annex II of MARPOL 73/78 as
called for by regulation 14 of Annex II and that the arrangements and equipment of the vessel prescribed in the
manual are in all respects satisfactory;

3

That the vessel complies with the requirements of the Guidelines and Annex II to MARPOL 73/78 for the carriage in
bulk of the following products provided that all relevant operational provisions of the Guidelines and Annex II are
observed:

Products (refer to Notes 1, 2 on
completion of Certificate)

Conditions of carriage
(tank numbers, etc.)

Pollution Category

Tank numbers referred to in this list are identified on attachment 1, showing a
signed and dated simplified tank plan.
Continued on attachment 2, additional signed and dated sheets.

U.S. DEPT. OF HOMELAND SECURITY, USCG, CG-5148C, (Rev. 04-09)

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4

That, in accordance with 1.4 of the Guidelines and 2.8.2 of the IBC Code, the provisions of the Guidelines and
the Code are modified in respect of the vessel in the following manner;
___________________________________________________________________________________________
___________________________________________________________________________________________

5

That the ship must be loaded:
.1 in accordance with the loading conditions provided in the approved loading manual; stamped and dated
____________________ and signed by a responsible officer of the Administration, or of an organization
recognized by the Administration;
.2 in accordance with the loading limitations appended to this Certificate.
Where it is required to load the ship other than in accordance with the above instructions, then the necessary
calculations to justify the proposed conditions should be communicated to the to the certifying Administration
who may authorize in writing the adoption of the proposed loading condition.

This certificate is valid until ________________________
Guidelines.
(ddmmmyyyy)

subject to surveys in accordance with 1.5 of the

Completion date of the survey on which this certificate is based: ______________________________
(ddmmmyyyy)

Issued at __________________________________________ , ______________________
(Place of issue of Certificate)
(Date of issue ddmmmyyyy)

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

Notes on completion of Certificate:
1

Products: products listed in appendix 1 to the Guidelines or which have been evaluated by the Administration in
accordance with 1.2.4 of the Guidelines should be listed. In respect of the latter “new” products, any special
requirements provisionally prescribed should be noted.

2

Products: The list of products the vessel is suitable to carry should include the noxious liquid substances of
category Z, which are not covered by the Guidelines and should be identified as “IBC Code chapter 18 category
Z”.

U.S. DEPT. OF HOMELAND SECURITY, USCG, CG-5148C, (Rev. 04-09)

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Endorsement for Annual and Intermediate Surveys
THIS IS TO CERTIFY that at a survey required by 1.5.2 of the Code the ship was found to comply with the relevant
provisions of the Guidelines.

Annual Survey:

Signed:
_____________________________________
(Signature of duly authorized official)

Place:
_____________________________________
Date:
_____________________________________
Annual* /Intermediate* Survey:

Signed:
_____________________________________
(Signature of duly authorized official)

Place:
_____________________________________
Date:
_____________________________________
Annual* /Intermediate* Survey:

Signed:
_____________________________________
(Signature of duly authorized official)

Place:
_____________________________________
Date:
_____________________________________
Annual survey:

Signed:
_____________________________________
(Signature of duly authorized official)

Place:
_____________________________________
Date:
_____________________________________
____________
*

Delete as appropriate

U.S. DEPT. OF HOMELAND SECURITY, USCG, CG-5148C, (Rev. 04-09)

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ANNUAL/INTERMEDIATE SURVEY IN ACCORDANCE
WITH PARAGRAPH 1.5.6.8.3
THIS IS TO CERTIFY that, at an annual* /intermediate* survey in accordance with paragraph 1.5.8.6.3 of the Code,
the ship was found to comply with the relevant provisions of the Guidelines:

Signed:
_____________________________________
(Signature of duly authorized official)

Place:
_____________________________________
Date:
_____________________________________

ENDORSEMENT TO EXTEND THE CERTIFICATE IF VALID FOR
LESS THAN 5 YEARS WHERE PARAGRAPH 1.5.6.3 APPLIES
The ship complies with the relevant provisions of the Guidelines, and this Certificate shall, in accordance with
paragraph 1.5.6.3 of the Code, be accepted as valid until: ________________________

Signed:
_____________________________________
(Signature of duly authorized official)

Place:
_____________________________________
Date:
_____________________________________
ENDORSEMENT WHERE THE RENEWAL SURVEY HAS BEEN COMPLETED
AND PARAGRAPH 1.5.6.4 APPLIES
The ship complies with the relevant provisions of the Guidelines, and this Certificate shall, in accordance with
paragraph 1.5.6.4 of the Code, be accepted as valid until: ________________________

Signed:
_____________________________________
(Signature of duly authorized official)

Place:
_____________________________________
Date:
_____________________________________
____________
*

Delete as appropriate

U.S. DEPT. OF HOMELAND SECURITY, USCG, CG-5148C, (Rev. 04-09)

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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
PARAGRAPH 1.5.6.5 OR 1.5.6.6 APPLIES
This Certificate shall, in accordance with paragraph 1.5.6.5*/1.5.6.6*of the Code, be accepted as valid until:
__________________

Signed:
_____________________________________
(Signature of duly authorized official)

Place:
_____________________________________
Date:
_____________________________________

ENDORSEMENT FOR ADVANCEMENT OF ANNIVERSARY DATE WHERE
PARAGRAPH 1.5.6.8 APPLIES
in accordance with paragraph 1.5.6.8 of the Code, the new anniversary date is:
__________________
Signed:
_____________________________________
(Signature of duly authorized official)

Place:
_____________________________________
Date:
_____________________________________

____________
*

Delete as appropriate

U.S. DEPT. OF HOMELAND SECURITY, USCG, CG-5148C, (Rev. 04-09)

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Attachment 1 to the Certificate of Fitness
TANK PLAN
Name of ship:

____________________________________ IMO Number: _________________
BOW

PORT

STARBOARD

STERN

Date: ____________

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

U.S. DEPT. OF HOMELAND SECURITY, USCG, CG-5148C, (Rev. 04-09)

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Attachment 2 to the Certificate of Fitness
Continued list of products to those specified in section 3, and their conditions of carriage.
Products (refer to Notes 1, 2 on
completion of Certificate)

Date: ___________

Conditions of carriage
(tank numbers, etc.)

Pollution Category

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

U.S. DEPT. OF HOMELAND SECURITY, USCG, CG-5148C, (Rev. 04-09)

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Attachment 2 to the Certificate of Fitness
Continued list of products to those specified in section 3, and their conditions of carriage.
Products (refer to Notes 1, 2 on
completion of Certificate)

Date: ___________

Conditions of carriage
(tank numbers, etc.)

Pollution Category

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

U.S. DEPT. OF HOMELAND SECURITY, USCG, CG-5148C, (Rev. 04-09)

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Attachment 2 to the Certificate of Fitness
Continued list of products to those specified in section 3, and their conditions of carriage.
Products (refer to Notes 1, 2 on
completion of Certificate)

Date: ___________

Conditions of carriage
(tank numbers, etc.)

Pollution Category

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

U.S. DEPT. OF HOMELAND SECURITY, USCG, CG-5148C, (Rev. 04-09)

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Attachment 2 to the Certificate of Fitness
Continued list of products to those specified in section 3, and their conditions of carriage.
Products (refer to Notes 1, 2 on
completion of Certificate)

Date: ___________

Conditions of carriage
(tank numbers, etc.)

Pollution Category

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

U.S. DEPT. OF HOMELAND SECURITY, USCG, CG-5148C, (Rev. 04-09)

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Attachment 2 to the Certificate of Fitness
Continued list of products to those specified in section 3, and their conditions of carriage.
Products (refer to Notes 1, 2 on
completion of Certificate)

Date: ___________

Conditions of carriage
(tank numbers, etc.)

Pollution Category

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

U.S. DEPT. OF HOMELAND SECURITY, USCG, CG-5148C, (Rev. 04-09)

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Attachment 2 to the Certificate of Fitness
Continued list of products to those specified in section 3, and their conditions of carriage.
Products (refer to Notes 1, 2 on
completion of Certificate)

Date: ___________

Conditions of carriage
(tank numbers, etc.)

Pollution Category

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

U.S. DEPT. OF HOMELAND SECURITY, USCG, CG-5148C, (Rev. 04-09)

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Attachment 2 to the Certificate of Fitness
Continued list of products to those specified in section 3, and their conditions of carriage.
Products (refer to Notes 1, 2 on
completion of Certificate)

Date: ___________

Conditions of carriage
(tank numbers, etc.)

Pollution Category

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

U.S. DEPT. OF HOMELAND SECURITY, USCG, CG-5148C, (Rev. 04-09)

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Attachment 2 to the Certificate of Fitness
Continued list of products to those specified in section 3, and their conditions of carriage.
Products (refer to Notes 1, 2 on
completion of Certificate)

Date: ___________

Conditions of carriage
(tank numbers, etc.)

Pollution Category

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

U.S. DEPT. OF HOMELAND SECURITY, USCG, CG-5148C, (Rev. 04-09)

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Attachment 2 to the Certificate of Fitness
Continued list of products to those specified in section 3, and their conditions of carriage.
Products (refer to Notes 1, 2 on
completion of Certificate)

Date: ___________

Conditions of carriage
(tank numbers, etc.)

Pollution Category

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

U.S. DEPT. OF HOMELAND SECURITY, USCG, CG-5148C, (Rev. 04-09)

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Attachment 2 to the Certificate of Fitness
Continued list of products to those specified in section 3, and their conditions of carriage.
Products (refer to Notes 1, 2 on
completion of Certificate)

Date: ___________

Conditions of carriage
(tank numbers, etc.)

Pollution Category

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

U.S. DEPT. OF HOMELAND SECURITY, USCG, CG-5148C, (Rev. 04-09)

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