CG-5662 Ballast Water Reporting Form

OMB Control Number 1625-0069

BALLAST WATER REPORTING FORM
IS THIS AN AMENDED BALLAST REPORTING FORM? YES
1. VESSEL INFORMATION
Vessel Name:

2. VOYAGE INFORMATION
Arrival Port:

IMO Number:

Arrival Date (D/M/YYYY):

Owner:
Type:

Agent:
Last Port:

GT:
Call Sign:
Flag:
4. BALLAST WATER MANAGEMENT
Of tanks to be discharged, how many:

Exp. Date: 04/30/2012

✔

3. BALLAST WATER USAGE AND CAPACITY
Specify Units Below (m3, MT, LT, ST)
Total Ballast Water on Board:
Volume
Units
No. of Tanks in Ballast
m3

Country of Last Port:

Next Port:

NO

Total Ballast Water Capacity:
Volume
Units Total No. of Tanks on Ship
m3

Country of Next Port:

Total No. Ballast Water Tanks to be discharged:
Underwent Exchange:

Underwent Alternative Management:

Please specify alternative method(s) used, if any:
If no ballast treatment conducted, state reason why not:
Ballast management plan on board?

YES

NO

Management plan implemented?

IMO ballast water guidelines on board [res. A.868(20)]?

YES

YES

NO

NO

5. BALLAST WATER HISTORY: Record all tanks to be deballasted in port state of arrival; IF NONE, GO TO #6 (Use additional sheets as needed)
Tanks/
BW SOURCE
BW MANAGEMENT PRACTICES
BW DISCHARGE
Holds

List multiple
sources/tanks
separately

DATE
D/M/YYYY

PORT or
LAT. LONG.

VOLUME
(units)

TEMP
(units)

DATE
D/M/YYYY

ENDPOINT
LAT. LONG.

VOLUME
(units)

m3m3

CC

m3
m3

m3m3

CC

m3
m3

m3m3

CC

m3
m3

m3m3

CC

m3
m3

m3m3

CC

m3
m3

m3m3

CC

m3
m3

m3m3

CC

m3
m3

%
Exch

METHOD
(ER/FT/
ALT)

SEA
HT.
(m)

DATE
D/M/YYYY

PORT or
LAT. LONG.

ER
ER

ER
ER
ER
ER
ER

VOLUME
(units)

SALINITY
(units)

m3m3

sg sg

m3m3

sg sg

m3m3

sg sg

m3m3

sg sg

m3m3

sg sg

m3m3

sg sg

m3m3

sg sg

Ballast Water Tank Codes: Forepeak = FP, Aftpeak = AP, Double Bottom = DB, Wing = WT, Topside = TS, Cargo Hold = CH, Other = O
6. RESPONSIBLE OFFICER’S NAME AND TITLE, PRINTED AND SIGNATURE:

Released 12-01-2006

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NBICReportingForm.omb.pdf

Tanks/
Holds

BW SOURCE

List multiple
sources/tanks
separately

DATE
D/M/YYYY

PORT or
LAT. LONG.

VOLUME
(units)

BW MANAGEMENT PRACTICES
TEMP
(units)

DATE
D/M/YYYY

ENDPOINT
LAT. LONG.

VOLUME
(units)

m3

C

m3

m3

C

m3

m3

C

m3

m3

C

m3

m3

C

m3

m3

C

m3

m3

C

m3

m3

C

m3

m3

C

m3

m3

C

m3

m3

C

m3

m3

C

m3

m3

C

m3

m3

C

m3

m3

C

m3

m3

C

m3

m3

C

m3

m3

C

m3

%
Exch

METHOD
(ER/FT/
ALT)

ER
ER

ER
ER

ER

ER

ER

ER
ER
ER

ER
ER
ER
ER
ER
ER

ER

ER

BW DISCHARGE
SEA
HT.
(m)

DATE
D/M/YYYY

PORT or
LAT. LONG.

VOLUME
(units)

SALINITY
(units)

m3

sg

m3

sg

m3

sg

m3

sg

m3

sg

m3

sg

m3

sg

m3

sg

m3

sg

m3

sg

m3

sg

m3

sg

m3

sg

m3

sg

m3

sg

m3

sg

m3

sg

m3

sg

Ballast Water Tank Codes: Forepeak = FP, Aftpeak = AP, Double Bottom = DB, Wing = WT, Topside = TS, Cargo Hold = CH, Other = O