CG-5401A (04/15) Application for Certificate of Adequacy (COA) for Recept

APPLICATION FOR CERTIFICATE OF ADEQUACY (COA) FOR RECEPTION FACILITIES
FORM A
1. General. The United States as a party to the International Convention for the Prevention of Pollution from Ships, 1973, as modified by the Protocol of 1978
relating thereto (MARPOL 73/78) is required by Annex I and the Act to Prevent Pollution from Ships (33 U.S.C. 1901 et. seq.) to issue certificates to
reception facilities verifying their adequacy to receive oily waste from ships. Regulations implementing the United States waste reception facility program
are in 33 CFR 158 Code of Federal Regulations.
2. The Certificate of Adequacy remains valid until suspended or revoked.
3. Upon suspension or revocation, a Certificate of Adequacy shall be promptly returned to the issuing U.S. Coast Guard Captain of the Port (COTP).
4. The Application, as submitted, shall be permanently attached to and become a part of the Certificate of Adequacy upon issuance.
5. A copy of the Certificate of Adequacy with the Application attached shall be available at each port and terminal to which it applies and shall be available for
inspection by Coast Guard personnel and the master, person in charge or agent of an oceangoing ship using or intending to use the reception facility.
6. A copy of the Certificate of Adequacy shall be attached to the operations manual for marine oil transfer facilities described in 33 CFR 154.300.
7. The terminal/port person in charge identified in the Application shall notify the U.S. Coast Guard Captain of the Port (COTP) in writing within 10 days after
any of the reception facility information supplied under 33 CFR 158.140 changes. The terminal/port person in charge shall notify the U.S. Coast Guard
COTP in writing within 30 days after any of the terminal/port information supplied under 33 CFR 158.140 changes.
8. 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.

GENERAL INSTRUCTIONS
THE CERTIFICATE OF ADEQUACY (COA) APPLICATION
FORM A
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 value as calculated on the Coast Guard optional worksheet line "AY" or other calculation sheet.

3.B.

Enter the value as calculated on the Coast Guard optional worksheet line "AZ" or other calculation sheet. Calculate from vessel traffic at the
terminal/port for the last 12 months.

3.C.

Describe the waste the reception facility can receive. Enter "oil" for all types of oily waste.

3.D.

Describe the ship types or principal trades, e.g., crude tankers, product tankers, container ships, grain ships, fishing vessels, etc.

3.E.

Enter a value based upon discharging waste through a single connection. This is necessary since ships are not required to discharge waste
through multiple connections. Oily ballast discharge rates may be based on discharging through more than one connection if all of the vessels and
reception facilities have this capability.

3.F.

Enter a value upon discharging waste through a single connection. This is necessary since ships are not required to discharge waste through
multiple connections.

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

Terminal

Port

COTP Designated Port

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:

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

Mobile

Tank Truck

Tank Barge

Other

(Describe Other):
(1) NAME OF RECEPTION FACILITY:
(a) ADDRESS:
(b) NAME/TITLE PERSON-IN-CHARGE:
(c) OFFICE PHONE NUMBER:
(d) SIGNATURE OF TERMINAL
PERSON-IN-CHARGE:
3. RECEPTION AND TRANSFER REQUIREMENTS
A. ESTIMATED DAILY CAPACITY OF RECEPTION FACILITY:

(metric tons)

B. ESTIMATED DAILY CAPACITY REQUIREMENT OF THE TERMINAL/PORT:

(metric tons)

C. TYPES OF WASTE THE RECEPTION FACILITY CAN RECEIVE:
D. SHIP TYPES OR PRINCIPAL TRADES OF SHIPS VISITING TERMINAL(S):

E. OILY BALLAST WASTE TRANSFER RATE (GPM):

(GPM)

F. ALL OTHER OILY RESIDUES AND MIXTURES TRANSFER RATE (GPM):

(GPM)

G. RECEPTION FACILITY CAN RECEIVE ALL THE OILY BALLAST FROM SHIPS VISITING
THE TERMINAL OR PORT WITHIN 10 HOURS OF WASTE TRANSFER COMMENCEMENT.
Enter either "YES", "NO", OR "N/A".

(Yes, No, N/A)

(If entering other than "YES" explain):
H. RECEPTION FACILITY CAN RECEIVE ALL OTHER OILY RESIDUES AND MIXTURES
FROM SHIPS VISITING THE TERMINAL OR PORT WITHIN 4 HOURS OF WASTE
TRANSFER COMMENCEMENT. Enter either "YES", "NO", OR "N/A".

(Yes, No, N/A)

(If entering other than "YES" explain):
I.

RECEPTION FACILITY FOR OIL WASTE WILL BE PROVIDED WITHIN 24 HOURS OF
NOTIFICATION. Enter either "YES", "NO", OR "N/A".

(Yes, No, N/A)

(If entering other than "YES" explain):
J. OILY WASTE WILL BE TRANSFERRED PRIOR TO SHIP LEAVING SHIP REPAIR YARD.
Enter "YES", "NO", OR "N/A".

(Yes, No, N/A)

(If entering other than "YES" explain):
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:
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DATE SIGNED:
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RECEPTION FACILITY INFORMATION SHEET
********** THIS PAGE FOR COMPLETION BY U.S. COAST GUARD **********

COAST GUARD COTP COMPLETE THE FOLLOWING INFORMATION AND FORWARD TO
DISTRICT (m) FOR QUARTERLY SUBMISSION TO COMMANDANT (G-FAC-2)
COTP ISSUING CERTIFICATE OF ADEQUACY:
NAME OF TERMINAL/PORT:
LOCATION OF TERMINAL/PORT (City/State):
NAME OF PERSON IN CHARGE:
PHONE NUMBER:

TYPE OF WASTE THE RECEPTION FACILITY CAN RECEIVE:
DAILY CAPACITY OF RECEPTION FACILITY (metric tons):
OILY BALLAST WASTE TRANSFER RATE (GPM):
ALL OTHER OILY RESIDUES AND MIXTURES TRANSFER RATE (GPM):

Privacy Act Statement

Authority: The United States as a party to the International Convention for the Prevention of Pollution from Ships, 1973, as modified by the Protocol of 1978 relating thereto (MARPOL
73/78) is required by Annex I and the Act to Prevent Pollution from Ships (33 U.S.C. 1901 et. seq.) to issue certificates to reception facilities verifying their adequacy to receive oily
waste from ships. Regulations implementing the United States waste reception facility program are in 33 CFR 158 Code of Federal Regulations.
Purpose: Waterfront Facilities are required to be certified to have adequate reception capabilities when receiving Oily mixtures from oceangoing tankers and any other oceangoing
ships 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 discharge of Oil pollution, 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 3 hours. 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

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