CG-5401C Application for Certifiate of Adequacy for Reception Fac

OMB. NO. Approved 1625-0045
Exp. Date: 11/30/2011
Burden hours: .75 per response

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

Application for a Reception Facility Certificate of
Adequacy for Garbage
FORM C

The Act to Prevent Pollution From Ships (33 USC 1901) authorizes the Department of Homeland Security to issue certificates to Terminals and Ports
verifying their adequacy to receive operational garbage from ships. Regulations implementing this program are in 33 CFR Code of Federal
Regulations Part 158. To continue to receive ships at a port or terminal an applicant must hold a Certificate of Adequacy for Garbage if it receives
oceangoing tankers, or any other oceangoing ship of 400 gross tons or more, carrying residues and mixtures containing oil; or if it receives
oceangoing ships carrying Noxious Liquid substances. To receive a Certificate of Adequacy for Garbage, application is required on FORM C.

Definitions:
"Terminal":

an onshore facility or an offshore structure located in the navigable waters of the United States or subject to the jurisdiction of the
United States and used, or intended to be used, as a fac ility for the transfer or other handling of a harmful substance. The definition of
"navigable waters" for the purposes of this section may be found in 33 CFR 2.05-25.

"Port":

(1) a group of terminals that combines to act as a unit and be considered a port for purposes of this part; (2) a port authority or other
organization that chooses to be considered a port for purposes of this part. For the purposes of Annex V of MARPOL 73/78, Port
also means a commercial fishing facility, recreational boating facility and a mineral and oil industry shorebase.

A. Terminal Section:
1. Complete this section if you are applying as a SINGLE TERMINAL.

Name of Terminal

Street Address

City

State

Zip Code

2. Check the following boxes if the terminal receives or discharges any of
the following cargoes from vessels visiting the terminal:
Oil
Oily wastes
Fuel
Bulk dry cargo
Explosives
Hazardous Substances
Fish
Other

Phone Number (Enter Area Code)
After completing this section go to Section C.

Receive
Receive
Receive
Receive
Receive
Receive
Receive
Receive

3. Check the following boxes if the terminal handles or services any of the
following vessels:
Vessels of Foreign registry
U.S. Vessels on domestic trade
U.S. Vessels in foreign trade
Passenger vessels
Vessels servicing the offshore
Mineral and Oil industry

Name of Terminal Person-in-Charge

Discharge
Discharge
Discharge
Discharge
Discharge
Discharge
Discharge
Discharge

Unmanned Barges
Chemical ships
Container ships
Break bulk ships
Ferry boat ships
Fishing ships

B. Port Section:
1. Complete this section if you are applying as a PORT.

Name of Terminal

Street Address

City

State

Name of Terminal Person-in-Charge

Zip Code

Number of Terminals which
will be members of this
Port?:

Phone Number (Enter Area Code)

The Coast Guard estimates that the average burden hours 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 DHS/USCG, Old Executive
Office Building, Washington, DC 20503.

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B. Port Section (continued) Individual terminal data:
Ports are to complete the following entries for each individual terminal which is a member of the port.
2.
5. Check the following boxes if the terminal receives or discharges any of
the following cargoes from vessels visiting the terminal:
Oil
Oily wastes
Fuel
Bulk dry cargo
Explosives
Hazardous Substances
Fish
Other

Name of Terminal

Street Address

City

State

Zip Code

Name of Terminal Person-in-Charge

Vessels of Foreign registry
U.S. Vessels on domestic trade
U.S. Vessels in foreign trade
Passenger vessels
Vessels servicing the offshore
Mineral and Oil industry

Signature of Person-in-Charge of Terminal
(Signature indicates Terminal Acknowledges that terminal agrees and
consents to being considered as a member of the port, described in
Section B.)
3.

Unmanned Barges
Chemical ships
Container ships
Break bulk ships
Ferry boat ships
Fishing ships

7. Check the following boxes if the terminal receives or discharges any of
the following cargoes from vessels visiting the terminal:
Oil
Oily wastes
Fuel
Bulk dry cargo
Explosives
Hazardous Substances
Fish
Other

Name of Terminal

Street Address

State

Zip Code

Name of Terminal Person-in-Charge

Discharge
Discharge
Discharge
Discharge
Discharge
Discharge
Discharge
Discharge

Receive
Receive
Receive
Receive
Receive
Receive
Receive
Receive

8. Check the following boxes if the terminal handles or services any of the
following vessels:
Vessels of Foreign registry
U.S. Vessels on domestic trade
U.S. Vessels in foreign trade
Passenger vessels
Vessels servicing the offshore
Mineral and Oil industry

Phone Number (Enter Area Code)

Signature of Person-in-Charge of Terminal
(Signature indicates Terminal Acknowledges that terminal agrees and
consents to being considered as a member of the port, described in
Section B.)
4.

Unmanned Barges
Chemical ships
Container ships
Break bulk ships
Ferry boat ships
Fishing ships

9. Check the following boxes if the terminal receives or discharges any of
the following cargoes from vessels visiting the terminal:
Oil
Oily wastes
Fuel
Bulk dry cargo
Explosives
Hazardous Substances
Fish
Other

Name of Terminal

Street Address

City

Receive
Receive
Receive
Receive
Receive
Receive
Receive
Receive

6. Check the following boxes if the terminal handles or services any of the
following vessels:

Phone Number (Enter Area Code)

City

Discharge
Discharge
Discharge
Discharge
Discharge
Discharge
Discharge
Discharge

State

Zip Code

Name of Terminal Person-in-Charge

Discharge
Discharge
Discharge
Discharge
Discharge
Discharge
Discharge
Discharge

Receive
Receive
Receive
Receive
Receive
Receive
Receive
Receive

10. Check the following boxes if the terminal handles or services any of the
following vessels:
Vessels of Foreign registry
U.S. Vessels on domestic trade
U.S. Vessels in foreign trade
Passenger vessels
Vessels servicing the offshore
Mineral and Oil industry

Phone Number (Enter Area Code)

Signature of Person-in-Charge of Terminal
(Signature indicates Terminal Acknowledges that terminal agrees and
consents to being considered as a member of the port, described in
Section B.)
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Unmanned Barges
Chemical ships
Container ships
Break bulk ships
Ferry boat ships
Fishing ships

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Page 3. of CG-5401C (6-04)

Section C
1. Does the terminal or port receive more than 25 visits from vessels arriving from foreign ports (except Canada), Hawaii or any territories or
possessions of the United States?
YES

NO (If the answer is "NO" go to question No. 3)

2. Does the terminal or port have facilities approved by the Administrator, Animal and Plant Health Inspection Service, U.S. Department of
Agriculture, for the disposal of garbage from foreign ports (except Canada), Hawaii or any Territories or Possessions of the United States in
accordance with Title 9 Code of Federal Regulations Part 94.
YES

NO (If the answer is "NO" you may attach a waiver request in accordance with 33 CFR 158 on a separate
attached sheet.)

Name of APHIS Approved Facility

Type (Incinerator, Sterilizer, Autoclave, etc.)

City

State

Phone Number

3. For those terminal(s)/port(s) requiring the services of an Animal and Plant Health Inspection Service approved facility, would the terminal or port
receive all garbage from these ships visiting the terminal/port within 24 hours of vessel after notification of need for such services is given?
YES

NO (If the answer is "NO" you may attach a waiver request in accordance with 33 CFR 158 on a separate
attached sheet.)

4. Is the terminal or port able to receive all garbage as defined in 33 CFR 158.120 which the master or person-in-charge of a ship desires to
discharge, except:
(1) large quantities of spoiled or damaged cargoes not normally expected to be discharged by a ship; or
(2) garbage from ships not having commercial transactions with that terminal or port?
YES

NO (If the answer is "NO" you may attach a waiver request in accordance with 33 CFR 158 on a separate
attached sheet.)

The terminal/port person-in-charge identified in the Application shall notify the U.S. Coast Guard Captain of the Port (COTP) in writing 30 days after
any of the terminal/port information supplied under 33 CFR 158.165(b)(3) changes.
Civil Penalties. A person who after notice and an opportunity for a hearing, is found:
a. to have made a false, fictitous 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.

CERTIFICATION
I hereby certify that the information provided in this application for a waste reception facility certificate of adequacy for
reception facilities receiving garbage 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

Mail the application to: THE LOCAL CAPTAIN OF THE PORT OFFICE
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