Form CG-6083 Application for Approval/Revision of Pollution Response

OMB Approval No. 1625-0066
SUBMISSION DATE:

Department of Homeland Security
United States Coast Guard
CG-6083 (05-06)

APPLICATION FOR
APPROVAL/REVISION OF
VESSEL POLLUTION
RESPONSE PLANS

Vessel Response Plan Review Team
Commandant, USCG (CG-3PCV-1)
2100 Second St. S.W Rm. 2100
Washington, DC 20593
Fax: 202-372-1921
1. PLAN HOLDER (Company and POC):

VRP CONTROL NUMBER:

VESSEL NAME:

1.b. TELEPHONE:

1.a. ADDRESS:

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

2.a. ADDRESS:

2. PLAN PREPARER:

2.c. FAX:
2.d. E-MAIL:
( Same as block 1)

4. SUBMISSION TYPE (Check all that apply):

3. PLAN TYPE (Check all that apply):

 Vessel Response Plan for Oil (VRP)
 Primary Carrier
 Secondary Carrier
 Vessel Response Plan for HazSub
(HazSub)

 Nontank Vessel Response Plan (NTVRP)
 Shipboard Oil Pollution Emergency Plan
(SOPEP)
 Shipboard Marine Pollution Emergency
Plan (SMPEP)
 Shipboard Marine Pollution Emergency
Plan for Noxious Liquid Substances
(SMPEP-NLS)

 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))
 Other (Please explain below)

6. OTHER EXPLAINED

5. ACTION (Check all that apply):

 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)

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:
I, _______________________________, certify that this submission meets all applicable requirements set forth in 33 CFR 155 and/or NVIC 01-05 and that
we have identified and ensured the availability of, through contract or other approved means, the necessary private resources to respond, to the maximum
extent practicable, to a worst case discharge or substantial threat of such a discharge from the vessel. The resources hereafter identified are listed with their
permission. (See 18 USC 1001)
Authorizing Signature:_____________________________________________________________________

Date:____________________

9. SOPEP/SMPEP AUTHORIZATION:
Authorizing Signature:_____________________________________________________________________

Date:____________________

NOTE:
1. This application and attachments may be faxed or emailed 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-3PCV), U.S. Coast Guard Paperwork Reduction Project (1625-0066), Washington, DC 20593-0001.

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 among industry, simplify the review process among Coast Guard personnel, and
promote a standardized procedure in an attempt to lessen 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-3PCV-1) Room 2100,
2100 Second St. S.W. Washington, DC 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 202-372-1921 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 and is intended to act as a valid certification statement, then a hard copy
with an original signature must be mailed.
INSTRUCTIONS
BLOCK 1: Enter the Plan Holder information. Include company name and point of contact.
BLOCK 1.a.: Enter the address for the Plan Holder. Include: street, city, state/province, and zip/postal code.
BLOCK 1.b.: Enter the telephone number for the Plan Holder point of contact. Include country and area code as applicable.
BLOCK 1.c.: Enter the fax number for the Plan Holder point of contact. Include country and area code as applicable.
BLOCK 1.d.: 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 2.a.: Enter the address for the Plan Preparer. Include: street, city, state/province, and zip/postal code.
BLOCK 2.b.: Enter the telephone number for the Plan Preparer. Include country and area code as applicable.
BLOCK 2.c.: Enter the fax number for the Plan Preparer. Include country and area code as applicable.
BLOCK 2.d.: 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: Authorizing personnel should read and sign certifying that the submitted plan meets the
requirements of 33 CFR 155. Authorizing persons are those that accept liability for the compliance of the vessel(s) listed in
the submitted plan in the event of an incident or marine casualty. Authorizing personnel include, but are not limited to: the
vessel owner, the vessel operator, or the plan preparer.
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.