CG-5401D (04/15) Application for a Reception Facility Certificate of Adeq

DEPARTMENT OF HOMELAND SECURITY

OMB No. 1625-0045

U.S. Coast Guard
Exp. Date: 08/31/2018
APPLICATION FOR A RECEPTION FACILITY CERTIFICATE OF ADEQUACY FOR OZONE
DEPLETION SUBSTANCES AND EXHAUST GAS CLEANING SYSTEM RESIDUE
FORM D
The Act to Prevent Pollution From Ships (33 U.S.C. 1901 et. seq.) authorizes the Secretary of the Department of Homeland
Security to issue certificates to Terminals and Ports verifying their adequacy to receive Ozone depletion substances (ODS) and
exhaust gas cleaning systems residues (EGCS) from ships. Regulations implementing Regulations Part 158. To continue to
receive ships at a port or terminal an applicant must hold a Certificate of Adequacy for ODS or EGCS if it receives oceangoing
tankers, or any other oceangoing ship of 400 gross tons or more requesting to discharge ODS or EGCS . To receive a
Certificate of Adequacy for ODS or EGCS, application is required on FORM D.
Definitions:
“Terminal": an on shore facility or an off shore 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 facility 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 MARPOL73/78,
Port also means a commercial fishing facility, recreational boating facility and a mineral and oil industry shore base.

A. Terminal Section

1. Complete this section if you are applying as a SINGLE TERMINAL

2. Check the following boxes if the terminal receives or discharges any of the
following cargoes from vessels visiting the terminal:

Name of Terminal
Street Address
City, State, Zip Code

Name of Terminal Person-in-Charge
Phone Number (Enter Area Code)

Oil

Discharge

Receive

Oily wastes

Discharge

Receive

Fuel

Discharge

Receive

Bulk dry cargo

Discharge

Receive

Explosives

Discharge

Receive

Hazardous Substances

Discharge

Receive

Fish

Discharge

Receive

Other

Discharge

Receive

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

After completing this section go to Section C.

Vessels of foreign registry

Unmanned barges

U.S. Vessels on domestic trade

Chemical ships

U.S. Vessels in foreign trade

Container ships

Passenger vessels

Break bulk ships

Vessels servicing the offshore
mineral and oil industry

Fishing ships

Ferry boat ships

B. Port Section

1. Complete this section if you are applying as a PORT
Name of Terminal
Street Address

Number of Terminal which we
will be members of this Port?

City, State, Zip Code
Name of Terminal Person-in-Charge
Phone Number (Enter Area Code)

CG-5401D (04/15)

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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.

Check the following boxes if the terminal receives or discharges any of the following
cargoes from vessels visiting the terminal:

Name of Terminal
Street Address
City, State, Zip Code
Name of Terminal Person-in-Charge
Phone Number (Enter Area Code)

Street Address
City, State, Zip Code
Name of Terminal Person-in-Charge

Street Address
City, State, Zip Code
Name of Terminal Person-in-Charge

Receive

Fuel

Discharge

Receive

Bulk dry cargo

Discharge

Receive

Explosives

Discharge

Receive

Hazardous substances

Discharge

Receive

Fish

Discharge

Receive

Other

Discharge

Receive

Vessels of foreign registry

Unmanned barges

U.S. Vessels on domestic trade

Chemical ships

U.S. Vessels in foreign trade

Container ships

Passenger vessels

Break bulk ships

Vessels servicing the offshore
mineral and oil industry

Fishing ships
Ferry boat ships

Oil

Discharge

Receive

Oily wastes

Discharge

Receive

Fuel

Discharge

Receive

Bulk dry cargo

Discharge

Receive

Explosives

Discharge

Receive

Hazardous substances

Discharge

Receive

Fish

Discharge

Receive

Other

Discharge

Receive

Vessels of foreign registry

Unmanned barges

U.S. Vessels on domestic trade

Chemical ships

U.S. Vessels in foreign trade

Container ships

Passenger vessels

Break bulk ships

Vessels servicing the offshore
mineral and oil industry

Fishing ships
Ferry boat ships

Oil

Discharge

Receive

Oily wastes

Discharge

Receive

Fuel

Discharge

Receive

Bulk dry cargo

Discharge

Receive

Explosives

Discharge

Receive

Hazardous substances

Discharge

Receive

Fish

Discharge

Receive

Other

Discharge

Receive

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

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.)

CG-5401D (04/15)

Discharge

Check the following boxes if the terminal receives or discharges any of the following
cargoes from vessels visiting the terminal:

Name of Terminal

Phone Number (Enter Area Code)

Oily wastes

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

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.

Receive

Check the following boxes if the terminal receives or discharges any of the following
cargoes from vessels visiting the terminal:

Name of Terminal

Phone Number (Enter Area Code)

Discharge

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

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.

Oil

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Vessels of foreign registry

Unmanned barges

U.S. Vessels on domestic trade

Chemical ships

U.S. Vessels in foreign trade

Container ships

Passenger vessels

Break bulk ships

Vessels servicing the offshore
mineral and oil industry

Fishing ships
Ferry boat ships

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SECTION C (33 CFR 158)
1. Does the terminal or port receive visits from vessels, requiring reception facilities for discharge for ozone depletion
substances?
YES

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

2. Is the port or terminal operator able to provide the ship with information regarding the nearest authorized EPA ODS handling
and disposal facility in accordance with EPA ODS program regulations?
YES (If the answers is "YES" please fill in the
information below.)

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 EPA Approved ODS Facility
City

State

Phone Number

3. Is the terminal or port able to receive EGCS residues as defined in 33 CFR 158 which the master or person-in-charge of a
ship desires to discharge?
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, 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 $8,000 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 $40,000 for each violation.

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.
PRINTED OR TYPED NAME OF PERSON IN CHARGE:
SIGNATURE OF TERMINAL/PORT
PERSON IN CHARGE:

DATE SIGNED:

Privacy Act Statement
Authority: The Act to Prevent Pollution From Ships (33 U.S.C 1901 et. seq.) authorizes the Department of Homeland Security to issue certificates to
Terminals and Ports verifying their adequacy t o receive Ozone depletion substances (ODS) and exhaust gas cleaning systems residues (EGCS) from ships .
Regulations implementing this program are in 33 CFR Code Federal Regulations Part 158. To continue to receive ships at a port or terminal an applicant must
hold a Certificate of Adequacy for ODS or EGCS if it receives oceangoing tankers, or any other oceangoing ship of 400 gross tons or more requesting to
discharge ODS or EGCS. To receive a Certificate of Adequacy for ODS or EGCS, application is required on FORM D.
Purpose: Waterfront Facilities are required to be certified to have adequate reception capabilities when receiving operational ODS or EGCS from ocean going
tankers, or any other ocean going ship of 400 gross tons or more.
Routine Uses: The information supplied on the form will be used by and disclosed to Coast Guard personnel. Additionally, the Coast Guard may share the
information with law enforcement or other government agencies as necessary to respond to any incidents that may occur as a result of any Marine Pollution by
ODS or EGCS or pursuant to its published Privacy Act system of records notice.
Disclosure: Furnishing this information is voluntary; however, failure to furnish the requested information may delay or prevent the issuance of the Certificate of
Adequacy (Form CG-5401).
Burden Statement: The Coast Guard estimates that the average burden for this report is 30 minutes. You may submit any comments concerning the accuracy of this burden estimate
or any suggestions for reducing the burden to: Commandant (CG-FAC-2), U.S. Coast Guard, 2703 Martin Luther King Jr Ave SE Stop 7501, Washington, DC 20593-7501 or Office of
Management and Budget, Paperwork Reduction Project (1625-0045), Washington, DC 20593.

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

CG-5401D (04/15)

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