CG-5401B Application for Certificate of Adequacy for Reception Fa

INSTRUCTIONS

The Certificate of Adequacy (COA) Application
FORM B
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 capacity of the Reception Facility to handle the specified wastes.
3.H. Only ship repair yards need complete this line item.
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 Regulatory Affairs, Attn.: Desk Officer for DOT/USCG, Old Executive
Building, Washington, DC 20503.

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

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

U.S. DEPARTMENT OF
HOMELAND SECURITY
U.S. COAST GUARD
CG-5401B (Rev. 6-04)

Application For a Reception Facility Certificate of Adequacy
For Noxious Liquid Substance (NLS) Residues and
Mixtures Containing NLS Residues

1. PARTICULARS OF TERMINAL OR PORT
A. APPLYING AS: (Check one)

Terminal

COTP Designated Port

Port

Ship Repair Yard

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) Office Phone Number

(

)

(

)

(d) Signature of Terminal Person-in-Charge
(2) Name of Terminal
(a) Address of Terminal

(b) Name/Title Person-in-Charge
(c) Office Phone Number
(d) 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. NAME OF RECEPTION FACILITY
B. ADDRESS

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

C. NAME AND TITLE OF PERSON IN CHARGE
D. OFFICE PHONE NUMBER OF PERSON IN CHARGE (

)

E. TYPE OF RECEPTION FACILITY: (Check those that apply)
Fixed

Mobile

Tank Truck

Tank

Other

(Describe other)
3. TYPE OF NLS CARGO OR RESIDUES UNLOADED AT THE TERMINAL OR PORT DURING THE LAST 12
MONTHS: ( Check the boxes that apply. If 3.A., 3.B., or 3.C. is checked, indicate the specific NLS handled on an
attached sheet or check the appropriate cargoes on the attached COTP optional NLS cargo list:
A. Category A
B. Category B solidifying or high viscosity
C. Category C solidifying or high viscosity
D. Category B non-solidifying or non-high viscosity
E. Category C non-solidifying or non-high viscosity
F. Category D
4. TERMINAL AND PORT REQUIREMENTS: (Only complete this section if the items 3.B., 3. C., 3.D., or 3.E. are
checked.)
A. WILL THE PORT OR TERMINAL BE CAPABLE OF RECEIVING NLS CARGO
DURING TANK STRIPPING OPERATIONS FROM SHIPS AT AN INSTANTANEOUS
FLOW RATE OF 6 CUBIC METERS (158.4 Gallons) PER HOUR WITHOUT THE BACK
PRESSURE EXCEEDING 101.6 kPa/sec (14.7 pounds per square inch gauge) AT THE
POINT WHERE THE SHORE CONNECTION MEETS THE SHIPS MANIFOLD?
No
Yes
B. WILL THE INSTRUCTION MANUAL THAT LISTS THE EQUIPMENT AND PROCEDURES
REQUIRED BY LINE ITEM 4.A. BE AVAILABLE AT THE TERMINAL PORT?

Yes

No

5. RECEPTION FACILITY REQUIREMENTS: (Only complete this section if line items 3.A., 3. B., or 3.C. are
checked. For line items 5.A. and 5.B. enter either the capacity or "N/A." for the items 5.C. through 5.G. enter
either "YES," "NO," or "N/A". If entering "NO" explain on a separate attached sheet).
A. ESTIMATED DAILY CAPACITY OF RECEPTION FACILITY TO RECEIVE NLS
RESIDUES RESULTING FROM PREWASH OPERATIONS:
(Cubic Meters)
B. ESTIMATED DAILY CAPACITY REQUIREMENT OF THE TERMINAL/PORT TO
RECEIVE NLS RESIDUES RESULTING FROM PREWASH OPERATIONS:
(Cubic Meters)
C. CAN THE RECEPTION FACILITY RECEIVE ALL NLS RESIDUES RESULTING
FROM PREWASH OPERATIONS FROM SHIPS WITHIN 10 HOURS AFTER NLS
Yes
No
N/A
RESIDUE TRANSFER BEGINS?
D. WILL THE RECEPTION FACILITIES FOR NLS RESIDUES BE PROVIDED WITHIN
24 HOURS AFTER NOTIFICATION BY A VESSEL INDICATING THE NEED FOR
N/A
Yes
No
RECEPTION FACILITIES?
E. WILL THE RECEPTION FACILITIES BE PROVIDED AT THE UNLOADING
TERMINAL/PORT?
F. DOES THE RECEPTION FACILITY HOLD EACH FEDERAL, STATE, AND LOCAL
PERMIT AND LICENSE REQUIRED BY ENVIRONMENTAL LAWS AND
REGULATIONS CONCERNING NLS RESIDUES?

Yes

No

N/A

Yes

No

N/A

G. CAN THE RECEPTION FACILITY RECEIVE ALL NLS RESIDUES PRIOR TO THE
SHIP LEAVING THE SHIP REPAIR YARD?

Yes

No

N/A

CERTIFICATION
I hereby certify that the information provided in this application for a waste reception facility
certificate of adequacy for reception facilities receiving noxious liquid substance (NLS) residues 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

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