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

U.S. DEPARTMENT OF HOMELAND SECURITY

OMB Approval No. 1625-0066
Exp. Date: 08/31/2013

U.S. Coast Guard
APPLICATION FOR APPROVAL/REVISION OF VESSEL POLLUTION RESPONSE PLANS
COMMANDANT, (CG-5431)
ATTN VESSEL RESPONSE PLANS
U.S. COAST GUARD
2100 SECOND ST. SW STOP 7581
WASHINGTON, DC 20593-7581
FAX: (202) 372-1921
1. PLAN HOLDER (Company and POC)

Submission Date

VRP Control Number

Vessel Name

Vessel Identification Number/IMO
Number

1a. ADDRESS

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

2. PLAN PREPARER

2a. ADDRESS

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

3. PLAN TYPE (Check all that apply):
Vessel Response Plan for Oil (Subpart D)
Primary Carrier
Manned
Unmanned
Secondary Carrier
Tanker Loading Cargo at a Facility
Permitted under the Trans-Alaska Pipeline
Authorization Act (Subpart E)
Vessel Carrying Animal Fats and
Vegetable Oils as Primary Cargo (Sub F)
Vessel Carrying other Non-Petroleum Oils
as a Primary Cargo (Subpart G)
Nontank Vessel Response Plan (NTVRP)
Shipboard Oil Pollution Emergency Plan
(SOPEP)
Shipboard Marine Pollution Emergency
Plan for Noxious Liquid Substances
(SMPEP)
Other (Please explain below)

4. SUBMISSION TYPE (Check all that apply):

5. Cargo Type (Check all that apply):

Original or New Plan Submission
Revision (Revision Number:________)
Add/Delete COTP Zone
Change in Owner/Operator

I
II

(33CFR155.1070(c)(1))

Vessel Name Change
Add/Change Oil Group Carried
OSRO Change
QI Change
Add/Delete Vessel
Change or Correction
Annual Review
Plan Deactivation
Plan Reactivation
Resubmission
5 Year Re-Approval
Change in Owner/Operator
(33CFR155.1070(b)(2))

Nontank VRP Recertification (2 Year)
Other (Please explain below)

III
IV
V
OFFICE USE ONLY
Date Received:
Due Date:
Date Completed:
WCD:

6. OTHER EXPLAINED

7. VESSEL RESPONSE PLAN CERTIFICATION AND AUTHORIZATION: (ensure signature and name is legible)
I, (print name)__________________________________________________, certify that this submission meets all applicable requirements
set forth in 33CFR155 / subpart D / subpart E / subpart F / subpart G / subpart I /, and/or, 33 U.S.C. 1321(j) (5), as applicable, and that I have
identified and ensured the availability of, through contract or other approved means, the necessary private resources to respond to the
maximum extent practical, a worst case discharge or a substantial threat of such a discharge from the vessel. (See 18 U.S.C. 1001)
Authorizing Signature: _________________________________________________________________

Date:____________________

8. I, as the plan holder, authorize plan preparation company: _________________________________ to act on my behalf regarding all
vessel response plan related correspondence.
Print: _____________________________________________ Signature: __________________________________________________
NOTE:
1.

2.

This application and attachments may be faxed to (202) 372-1921 or emailed to [email protected] providing that faxes are less than 15 pages
and electronic documents are less than 15 pages and less than 1.5 megabytes.
Submissions exceeding this size may be submitted online at homeport.uscg.mil/vrpexpress.

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-5431), U.S. Coast Guard Paperwork Reduction Project (1625-0066), Washington, DC 20593-0001.

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9. COMMENTS

Privacy Act Statement
a. Authority: 5 U.S.C. 301; 14 U.S.C. 89a; 14 U.S.C. 93(a) and (c); 14 U.S.C 632; the Federal Records Act; 33 U.S.C. 1228; 33 U.S.C.1321(j)(5); 33 CFR
151 and 155.
b. Purpose: to coordinate the review and issuance of approval for a Vessel Response Plan or MARPOL 73/78 Shipboard Oil Pollution Emergency
Plan/Shipboard Marine Pollution Emergency Plan.
c. Routine Uses: In addition to those disclosures generally permitted under 5 U.S.C. 552a(b) of the Privacy Act, these records or information contained
therein may specifically be disclosed outside the Department of Homeland Security as a routine use pursuant to 5 U.S.C.552a(b)(3) as follows: in
accordance with DH/USCG-013 Marine Information for Safety and Law Enforcement (MISLE) System of Records.
d. Disclosure: Completion/furnishing of this form is VOLUNTARY. However, failure to provide the requested information may result in a delay or the
inability to process or approve your Application for Approval/Revision of Vessel Pollution Response Plans and delay and/or prevent vessel operation in U.S.
waters and/or overseas.
INTRODUCTION: This application is offered as an optional replacement or supplement to submitting a cover letter. Submissions exceeding this size may
be submitted online at homeport.uscg.mil/vrpexpress. This application is intended to: simplify the plan submission process for industry, simplify the review
process for Coast Guard personnel, and promote a standardized procedure in an attempt to reduce 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-5431) COMMANDANT (CG-5431), ATTN
VESSEL RESPONSE PLANS, US COAST GUARD, 2100 2ND ST SW STOP 7581, WASHINGTON, DC 20593-7581. 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 to [email protected] and is intended to act as a valid certification statement, please ensure
that a legible signature is provided.
INSTRUCTIONS
BLOCK 1: Enter the Plan Holder information. Include company name and point of contact.
BLOCK 1a.: Enter the address for the Plan Holder. Include: street, city, state/province, and zip/postal code.
BLOCK 1b.: Enter the telephone number for the Plan Holder point of contact. Include country and area code as applicable.
BLOCK 1c.: Enter the fax number for the Plan Holder point of contact. Include country and area code as applicable.
BLOCK 1d.: 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 2a.: Enter the address for the Plan Preparer. Include: street, city, state/province, and zip/postal code.
BLOCK 2b.: Enter the telephone number for the Plan Preparer. Include country and area code as applicable.
BLOCK 2c.: Enter the fax number for the Plan Preparer. Include country and area code as applicable.
BLOCK 2d.: 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 type(s) of cargo the vessel(s) are carrying.
BLOCK 6: Explain in detail any submission that is not covered above.
BLOCK 7: For Vessel Response Plans: The vessel owner or operator (as defined in 33 CFR 155.1020) should read and sign the certification to indicate the
submitted plan meets the requirements of 33 CFR 155 subpart D, E, F, G or I (as applicable) for the vessel(s) listed. Certification indicates the vessel owner or
operator accepts responsibility for the compliance of the vessel(s) in the event of an incident or marine casualty. Certification statements must be submitted in
accordance with 33 CFR 155.1065(b) and 33 CFR 155.1070(d).
BLOCK 8: For Vessel Response Plans: The vessel owner or operator (as defined in 33 CFR 155.1020) should read and sign the statement giving the
contracted plan preparer ability to act on the owner/operator’s behalf regarding plan related correspondence.
BLOCK 9: Space for additional comments and suggestions.
CG-6083 (8/11)

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