CG-5461 International Pollution Prevention Certificate for the C

Form Approved
OMB No. 1625-0094

INTERNATIONAL POLLUTION PREVENTION
CERTIFICATE FOR THE CARRIAGE OF
NOXIOUS LIQUID SUBSTANCES IN BULK
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,
as amended (hereinafter referred to as "the Convention") under the authority of the
Government of:

United States of America
by the United States Coast Guard
Name of Ship

Distinctive Numbers
or Letters

Port of Registry

Gross Tonnage

IMO Number

THIS IS TO CERTIFY:
1.

That the ship has been surveyed in accordance with regulation 8 of Annex II of the Convention.

2.

That the survey showed that the structure, equipment, systems, fitting, arrangements, 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 II of the Convention.

3.

That the ship has been provided with a Procedures and Arrangements Manual as required by regulation 14 of Annex II of the
Convention, and that the arrangements and equipment of the ship prescribed in the Manual are in all respects satisfactory.

4.

That the ship complies with the requirements of Annex II to MARPOL 73/78 for the carriage in bulk of the listed Noxious
Liquid Substances in Attachment 1, provided that all relevant provisions of Annex II are observed.
*

This Certificate is valid until
subject to surveys in accordance with regulation 8 of Annex II of the Convention.
Issued at

,
Date of issue

Signature of authorized official issuing

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 (CG-3PCV), U.S. Coast Guard, 2100 2nd St, SW, Washington D.C. 20593-0001 or Office of
Management and Budget, Paperwork Reduction Project (1625-0094), Washington, DC 20503.
*

Insert the date of expiry as specified by the Administration in accordance with regulation 10.1 of Annex II of the Convention. The day and the month
of this date correspond to the anniversary date as defined in regulation 1.1 of Annex II of the Convention, unless amended in accordance with
regulation 10.8 of Annex II of the Convention.

U.S. Dept. of Homeland Security, USCG, CG-5461 (Rev. 08-06)

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ENDORSEMENT FOR ANNUAL AND INTERMEDIATE SURVEYS
THIS IS TO CERTIFY that, at a survey required by regulation 8 of Annex II of the Convention, the
ship was found to comply with the relevant provisions of the Convention:

Annual Survey:

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

Annual*/Intermediate* Survey:

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

Annual*/Intermediate* Survey:

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

Annual Survey:

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

*

Delete as appropriate.

U.S. Dept. of Homeland Security, USCG, CG-5461 (Rev. 08-06)

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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 II of the Convention, the ship was found to comply with the relevant provisions of the
Convention:
Signed:
(Signature of 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 II of the Convention, be accepted as valid
until
Signed:
(Signature of 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 II of the Convention, be accepted as valid
until
Signed:
(Signature of authorized official)
Place:
Date:

U.S. Dept. of Homeland Security, USCG, CG-5461 (Rev. 08-06)

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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 II of the Convention, be
accepted as valid until
Signed:
(Signature of authorized official)
Place:
Date:

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

In accordance with regulation 10.8 of Annex II of the Convention, the new anniversary
date is
Signed:
(Signature of authorized official)
Place:
Date:

U.S. Dept. of Homeland Security, USCG, CG-5461 (Rev. 08-06)

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ATTACHMENT 1 TO THE INTERNATIONAL POLLUTION PREVENTION FOR
CARRIAGE OF NOXIOUS LIQUID SUBSTANCES IN BULK CERTIFICATE
Noxious Liquid Substances

Date of issue

Conditions of Carriage
(tank numbers, etc.)

Pollution
Category

Signature and title of official issuing the certificate

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U.S. Dept. of Homeland Security, USCG, CG-5461 (Rev. 08-06)

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