Form CG-5401A Application for Certificate of Adequacy for Reception Fa

OMB No. Approved 1625-0045
Exp Date: 11/30/2011
Burden Hours=3 hours for new facilities

GENERAL INSTRUCTIONS
APPLICATION FOR CERTIFICATE OF ADEQUACY
FOR
RECEPTION FACILITIES

1. General . The United States as a party to the International Convention for the Prevention of Pollution from
Ships, 1973, as modified by the Protocol of 1978 relating thereto (MARPOL 73/78) is required by Annex I and
the Act to Prevent Pollution from Ships (33 USC 1901) to issue certificates to reception facilities verifying
their adequacy to receive oily waste from ships. Regulations implementing the United States waste reception
facility program are in 33 CFR 158 Code of Federal Regulations.
2. The Certificate of Adequacy remains valid until suspended or revoked.
3. Upon suspension or revocation, a Certificate of Adequacy shall be promptly returned to the issuing U.S.
Coast Guard Captain of the Port (COTP).
4. The Application, as submitted, shall be permanently attached to and become a part of the Certificate of
Adequacy upon issuance.
5. A copy of the Certificate of Adequacy with the Application attached shall be available at each port and
terminal to which it applies and shall be available for inspection by Coast Guard personnel and the master,
person in charge or agent of an oceangoing ship using or intending to use the reception facility.
6. A copy of the Certificate of Adequacy shall be attached to the operations manual for marine oil transfer
facilities described in 33 CFR 154.300.
7. The terminal/port person in charge identified in the Application shall notify the U.S. Coast Guard Captain of
the Port (COTP) in writing within 10 days after any of the reception facility information supplied under 33
CFR 158.140(b)(4) changes. The terminal/port person in charge shall notify the U.S. Coast Guard COTP in
writing within 30 days after any of the terminal/port information supplied under 33 CFR 158.140(b)(1)-(3)
changes.
8. Civil Penalties . A person who after notice and an opportunity for a hearing, is found:
a. to have made a false, fictitious or fraudulent statement or representation in any matter in which a
statement or representation is required to be made under the Act to Prevent Pollution from Ships, or the
regulations thereunder, shall be liable to the United States for a civil penalty, not to exceed $5,000 for
each statement or representation; or
b. to have violated the Act to Prevent Pollution from Ships, or the regulations issued thereunder, shall be
liable to the United States for a civil penalty not to exceed $25,000 for each violation.
The Coast Guard estimates that the average burden for this report form is 45 minutes. You may submit any
comments concerning the accuracy of this burden estimate or any suggestions for reducing the burden to:
Commandant (G-MEP-1), U.S. Coast Guard, Washington, DC 20593-0001 or Office of Management and
Budget, Office of Information and Regultory Affairs, Attn.: Desk Officer for DHS/USCG, Old Executive
Building, Washington, DC 20503.

U.S. DEPT. OF HOMELAND SECURITY, USCG, CG-5401A (Rev. 6-04)

INSTRUCTIONS
THE CERTIFICATE OF ADEQUACY (COA) APPLICATION

The following instructions for individual line items are provided to assist in completing the Application for a
Certificate of Adequacy (COA). If you have any questions or need assistance in completing the Application,
please contact the U.S. Coast Guard Captain of the Port (COTP) for your area. A list of definitions, which you
may find helpful in completing the Application, is provided in 33 Code of Federal Regulations Part 158
(33 CFR 158).
1.A.

Indicate terminal if you are applying as a single terminal or indicate port if you are applying as a
group of terminals. Do not mark "COTP Designated Port" unless you have a letter from the COTP
with such a designation. COTP designation of a facility or an area as a port is for unusual
situations. If you have a question as to whether COTP designation as a port applies to your
situation, contact the COTP for your area.

1.C. (1) For a terminal, enter the company or corporation name. For a port, enter the company,
corporation, port authority, or organization by which the group of terminals is legally known.
1.C.(3) Enter the name of a person authorized to act in behalf of the terminal or port.
1.C.(5) For a terminal, enter the company or corporation name. For a port, enter the company,
corporation, port authority, or organization of which the person in charge is a member.
1.D.(1) Those applying as terminals do not have to complete this section, since the information is the
same as in 1.C. Ports are to provide this information for each of the terminals indicated in 1.B.
2.A.(1) Enter the company or corporation name of the reception facility.
2.A.(5) Check as many of the types of reception facilities as may be used.
3.A.

Enter the value as calculated on the Coast Guard optional worksheet line "AY" or other calculation
sheet.

3.B.

Enter the value as calculated on the Coast Guard optional worksheet line "AZ" or other calculation
sheet. Calculate from vessel traffic at the terminal/port for the last 12 months.

3.C.

Describe the waste the reception facility can receive. Enter "oil" for all types of oily waste.

3.D.

Describe the ship types or principal trades, e.g., crude tankers, product tankers, container ships,
grain ships, fishing vessels, etc.

3.E.

Enter a value based upon discharging waste through a single connection. This is necessary since
ships are not required to discharge waste through multiple connections. Oily ballast discharge
rates may be based on discharging through more than one connection if all of the vessels and
reception facilities have this capability.

3.F.

Enter a value upon discharging waste through a single connection. This is necessary since ships
are not required to discharge waste through multiple connections.

OMB NO. APPROVED 1625-0045

FORM A
APPLICATION FOR A RECEPTION FACILITY
CERTIFICATE OF ADEQUACY
FOR OIL
1. PARTICULARS OF TERMINAL OR PORT
A. APPLYING AS: (Check one)

Terminal

COTP Designated Port

Port

B. NUMBER OF TERMINALS TO WHICH THIS APPLICATION APPLIES:
C. TERMINAL/PORT INFORMATION:
(1) NAME OF TERMINAL/PORT
(2) ADDRESS OF TERMINAL/PORT
(3) NAME OF TERMINAL/PORT
PERSON-IN-CHARGE
(4) TITLE/POSITION
(5) ORGANIZATION
(6) OFFICE PHONE NUMBER

(

)

D. INDIVIDUAL TERMINAL INFORMATION . If applying as a port, list the information indicated for each
terminal in the port. If more space is needed, continue on a separate sheet of paper and attach to the back
of the application. The signature of the person in charge of the terminal acknowledges that the terminal
agrees and volunteers to being considered as a member of the port, described in section 1, for purposes of
these reception facilities. Complete the terminal name, location, etc. below.
(1) NAME OF TERMINAL
(a). ADDRESS OF TERMINAL
(b).

NAME/TITLE PERSON-IN-CHARGE

(c).
(d).

OFFICE PHONE NUMBER
SIGNATURE OF TERMINAL
PERSON-IN-CHARGE

(

)

(

)

(2) NAME OF TERMINAL
(a). ADDRESS OF TERMINAL
(b).

NAME/TITLE PERSON-IN-CHARGE

(c).
(d).

OFFICE PHONE NUMBER
SIGNATURE OF TERMINAL
PERSON-IN-CHARGE

2. PARTICULARS OF RECEPTION FACILITY . Enter information for each reception facility used by the terminal/port.
If necessary, continue on a separate sheet and attach to the back of the Application.
A. (1) NAME OF RECEPTION FACILITY
(2) ADDRESS

U.S. DEPT. OF HOMELAND SECURITY, USCG, CG-5401A (Rev. 6-04)

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Page 2. of CG-5401A (Rev. 6-04)

(3) NAME AND TITLE OF PERSON IN CHARGE
(

(4) OFFICE PHONE NUMBER

)

(5) TYPE OF RECEPTION FACILITY: (Check those that apply)
FIXED

MOBILE

TANK TRUCK

TANK BARGE

OTHER

(Describe other)
3.

RECEPTION AND TRANSFER REQUIREMENTS :
A. ESTIMATED DAILY CAPACITY OF RECEPTION FACILITY:
B. ESTIMATED DAILY CAPACITY REQUIREMENT OF THE TERMINAL/PORT:

(metric tons)
(metric tons)

C. TYPES OF WASTE THE RECEPTION FACILITY CAN RECEIVE:
D. SHIP TYPES OR PRINCIPAL TRADES OF SHIPS VISITING TERMINAL(S)

E. OILY BALLAST WASTE TRANSFER RATE (GPM):
F. ALL OTHER OILY RESIDUES AND MIXTURES TRANSFER RATE (GPM):
G. RECEPTION FACILITY CAN RECEIVE ALL THE OILY BALLAST FROM SHIPS
VISITING THE TERMINAL OR PORT WITHIN 10 HOURS OF WASTE TRANSFER
COMMENCEMENT. Enter either "YES", "NO", OR "N/A".
(If entering other than "YES" explain.)
H. RECEPTION FACILITY CAN RECEIVE ALL OTHER OILY RESIDUES AND MIXTURES
FROM SHIPS VISITING THE TERMINAL OR PORT WITHIN 4 HOURS OF WASTE
TRANSFER COMMENCEMENT. Enter either "YES", "NO", OR "N/A".
(If entering other than "YES" explain.)
I. RECEPTION FACILITY FOR OIL WASTE WILL BE PROVIDED WITHIN 24 HOURS OF
NOTIFICATION. Enter either "YES", "NO", OR "N/A".
(If entering other than "YES" explain.)
J. OILY WASTE WILL BE TRANSFERRED PRIOR TO SHIP LEAVING SHIP REPAIR
YARD. Enter "YES", "NO", OR "N/A".
(If entering other than "YES" explain.)

CERTIFICATION
I HEREBY CERTIFY THAT THE INFORMATION PROVIDED IN THIS APPLICATION FOR A WASTE RECEPTION
FACILITY CERTIFICATE OF ADEQUACY IS COMPLETE, TRUE AND CORRECT TO THE BEST OF MY
KNOWLEDGE, INFORMATION, AND BELIEF.
SIGNATURE OF TERMINAL/PORT PERSON IN CHARGE
PRINTED OR TYPED NAME OF PERSON IN CHARGE
DATE SIGNED
2

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RECEPTION FACILITY INFORMATION SHEET
**********

THIS PAGE FOR COMPLETION BY U.S. COAST GUARD

**********

COAST GUARD COTP COMPLETE THE FOLLOWING INFORMATION AND FORWARD TO
DISTRICT (m) FOR QUARTERLY SUBMISSION TO COMMANDANT (G-WPE-3):
COTP ISSUING CERTIFICATE OF ADEQUACY
NAME OF TERMINAL/PORT
LOCATION OF TERMINAL/PORT (City/State)
NAME AND PHONE NUMBER OF PERSON IN CHARGE

(

)

TYPE OF WASTE THE RECEPTION FACILITY CAN RECEIVE
DAILY CAPACITY OF RECEPTION FACILITY (metric tons)
OILY BALLAST WASTE TRANSFER RATE (GPM)
ALL OTHER OILY RESIDUES AND MIXTURES
TRANSFER RATE (GPM)

3

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