CG-6083 Application for Approval/Revision of Vessel Pollution Re

OMB Approval No. 1625-0066

U.S. Department of Homeland Security
U.S. Coast Guard
CG-6083 (12-07)
Vessel Response Plan Review Team
Commandant, USCG (CG-5431)
2100 Second St. S.W Rm. 2100
Washington, DC 20593
Fax: (202) 372-1921
1. PLAN HOLDER (Company and POC)

SUBMISSION DATE

APPLICATION FOR
APPROVAL/REVISION OF
VESSEL POLLUTION
RESPONSE PLANS
1a. ADDRESS

VRP CONTROL NUMBER

VESSEL NAME

1b. TELEPHONE
1c. FAX
1d. E-MAIL

2. PLAN PREPARER

2a. ADDRESS

2b. TELEPHONE
2c. FAX
2d. E-MAIL

3. PLAN TYPE (Check all that apply):

4. SUBMISSION TYPE (Check all that apply):

Vessel Response Plan for Oil (Subpart D)
Primary Carrier
Manned
Unmanned
Secondary Carrier
Tanker Loading Cargo at a Facility
Permitted under the Trans-Alaska Pipeline
Authorization Act (Subpart E)
Vessel Carrying Animal Fats and
Vegetable Oils as Primary Cargo (Sub F)
Vessel Carrying other Non-Petroleum Oils
as a Primary Cargo (Subpart G)
Nontank Vessel Response Plan (NTVRP)
Shipboard Oil Pollution Emergency Plan
(SOPEP)
Shipboard Marine Pollution Emergency
Plan for Noxious Liquid Substances
(SMPEP)

5. ACTION (Check all that apply):

Original or New Plan Submission
Revision (Revision Number:________)
Add/Delete COTP Zone
Change in Owner/Operator
(33CFR155.1070(c)(1))

Vessel Name Change
Add/Change Oil Group Carried
OSRO Change
QI Change
Add/Delete Vessel
Change or Correction
Annual Review
Resubmission
5 Year Re-Approval
Change in Owner/Operator
(33CFR155.1070(b)(2))

Approval
(Applies to new, resubmitted, or
reactivated plans and revisions that
affect the plan holder, added
vessels, zone changes, and vessel
name changes.)
Duplicate Approval Letter
Corrected Approval Letter
Plan Deactivation
Plan Reactivation
Vessel Deactivation
Vessel Reactivation
Policy Interpretation
Plan Review Status
No Response Needed
Other (Please explain below)

Nontank VRP Recertification (2 Year)
Other (Please explain below)

6. OTHER EXPLAINED

OFFICE USE ONLY

7. ATTACHMENTS INCLUDED1:
Entire Plan
Revision Filing Instructions
Revision(s)

Vessel Specific Appendix
Geographic Specific Appendix
Plan Holder Information

Changed/Corrected Pages
Record of Changes
List of Effected Pages

8. VESSEL RESPONSE PLAN CERTIFICATION AND AUTHORIZATION: (ensure signature and name is legible)
I, (print name)__________________________________________________, certify that this submission meets all applicable requirements
set forth in (circle applicable subparts) 33CFR155 / subpart D / subpart E / subpart F / subpart G / and/or 33 U.S.C. 1321(j) (5), and that I have
identified and ensured the availability of, through contract or other approved means, the necessary private resources to respond to the
maximum extent practical, a worst case discharge or a substantial threat of such a discharge from the vessel. (See 18 U.S.C. 1001)
Authorizing Signature: _________________________________________________________________

Date:____________________

9. SOPEP/SMPEP AUTHORIZATION: (ensure signature and name is legible)
Authorizing Signature:__________________________________________________________________

Date:____________________

NOTE:
1. This application and attachments may be faxed to (202) 372-1921 or emailed to [email protected] providing that faxes are less than 15 pages and
electronic documents are less than 15 pages and less than 1.5 megabytes.
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 10 minutes. You may submit any comments concerning the accuracy of this burden or any
suggestions for reducing the burden to: Commandant (CG-5431), U.S. Coast Guard Paperwork Reduction Project (1625-0066), Washington, DC 20593-0001.

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Page 2 of CG-6083 (Rev. 12-07)

10. COMMENTS

INTRODUCTION: This application is offered as an optional replacement or supplement to submitting a cover letter. This application is
intended to: simplify the plan submission process for industry, simplify the review process for Coast Guard personnel, and promote a
standardized procedure in an attempt to reduce the amount of time required for the review process. When submitted properly, this
application meets the requirement for a Vessel Response Plan certification statement as required by 33 CFR 155.1065(b). This application
may be submitted with the plan(s) or revision(s) to the Vessel Response Plan Program (CG-5431) Room 2100, 2100 Second St. S.W.
Washington, D.C 20593-0001. To ensure Coast Guard receipt of your plan or revisions it is recommended that items be sent via trackable
means such as a courier service or the Postal Service’s Registered Mail system. This application may be submitted by facsimile to 202372-1921 and electronic mail only if the total submission is no greater than 15 pages per week and less than 1.5 megabytes. If this
application is faxed or emailed to [email protected] and is intended to act as a valid certification statement, please ensure that a legible
signature is provided.
INSTRUCTIONS
BLOCK 1: Enter the Plan Holder information. Include company name and point of contact.
BLOCK 1a.: Enter the address for the Plan Holder. Include: street, city, state/province, and zip/postal code.
BLOCK 1b.: Enter the telephone number for the Plan Holder point of contact. Include country and area code as applicable.
BLOCK 1c.: Enter the fax number for the Plan Holder point of contact. Include country and area code as applicable.
BLOCK 1d.: Enter a valid email address for the Plan Holder point of contact if available.
BLOCK 2: Enter the Plan Preparer information. Include company name and point of contact or plan writer. If the subject plan is prepared by
the Plan Holder, select the “Same as block 1” option
BLOCK 2a.: Enter the address for the Plan Preparer. Include: street, city, state/province, and zip/postal code.
BLOCK 2b.: Enter the telephone number for the Plan Preparer. Include country and area code as applicable.
BLOCK 2c.: Enter the fax number for the Plan Preparer. Include country and area code as applicable.
BLOCK 2d.: Enter a valid email address for the Plan Preparer if available.
BLOCK 3: Select the type(s) of plan(s) to be submitted with this application.
BLOCK 4: Select the type(s) of submission(s) enclosed with this application.
BLOCK 5: Select the action or response requested. Note: Approval letters will only be issued for plans that are new, resubmitted, or
reactivated, and for revisions that request a change in plan holder, added vessels, vessel name changes, and COTP zone
changes.
BLOCK 6: Explain in detail any submission that is not covered above.
BLOCK 7: Select the type(s) of attachments included with this application.
BLOCK 8: For Vessel Response Plans: The vessel owner or operator (as defined in 33 CFR 155.1020) should read and sign the certification
to indicate the submitted plan meets the requirements of 33 CFR 155 subpart D, E, F, or G (as applicable) for the vessel(s) listed.
Certification indicates the vessel owner or operator accepts responsibility for the compliance of the vessel(s) in the event of an
incident or marine casualty. Certification statements must be submitted in accordance with 33 CFR 155.1065(b) and 33 CFR
155.1070(d).
BLOCK 9: For Shipboard Oil Pollution Emergency Plans/Shipboard Marine Pollution Emergency Plans: This block should be completed by a
person authorized to write and revise the submitted plan.
BLOCK 10: Space for additional comments and suggestions.
U.S. Dept. of Homeland Security, USCG, CG-6083 (Rev. 12-07)

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