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

APPLICATION FOR CERTIFICATE OF ADEQUACY (COA) FOR RECEPTION FACILITIES
FORM B
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 II 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 B
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 capacity of the Reception Facility to handle the specified wastes.

5.G.

Only ship repair yards need complete this line item.

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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
NOXIOUS LIQUID SUBSTANCE (NLS) RESIDUES AND MIXTURES CONTAINING NLS RESIDUES
FORM B
1. PARTICULARS OF TERMINAL OR PORT
A. APPLYING AS: (Check one)

Terminal

Port

COTP Designated Port

Ship Repair Yard

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. TYPE OF NLS CARGO OR RESIDUES UNLOADED AT THE TERMINAL OR PORT DURING THE LAST 12 MONTHS:
(Check the boxes that apply.) If 3.A., 3.B., or 3.C. is checked, indicate the specific NLS handled on an attached sheet
or check the appropriate cargoes on the attached COTP optional NLS cargo list:
A. Category X

C. Category Y non-solidifying
or non-high viscosity
D. Category Z

E. Category OS

B. Category Y solidifying
or high viscosity
4. TERMINAL AND PORT REQUIREMENTS: (Only complete this section if the items 3.B., 3.C., 3.D., or 3.E. are checked.)
A. WILL THE PORT OR TERMINAL BE CAPABLE OF RECEIVING NLS CARGO DURING TANK

STRIPPING OPERATIONS FROM SHIPS AT AN INSTANTANEOUS FLOW RATE OF 6 CUBIC METERS

(158.4 Gallons) PER HOUR WITHOUT THE BACK PRESSURE EXCEEDING 101.6 kPa/sec (14.7 pounds
per square inch gauge) AT THE POINT WHERE THE SHORE CONNECTION MEETS THE SHIPS MANIFOLD?

(Yes, No)

B. WILL THE INSTRUCTION MANUAL THAT LISTS THE EQUIPMENT AND PROCEDURES REQUIRED

BY LINE ITEM 4.A. BE AVAILABLE AT THE TERMINAL PORT?

(Yes, No)

5. RECEPTION FACILITY REQUIREMENTS: (Only complete this section if line items 3.A.or 3.B. are checked. For line
items 5.A. and 5.B. enter either the capacity or "N/A." for the items 5.C. through 5.G. enter either "YES," "NO," or "N/A".
If entering "NO" explain on a separate attached sheet).
A. ESTIMATED DAILY CAPACITY OF RECEPTION FACILITY TO RECEIVE NLS RESIDUES
RESULTING FROM PREWASH OPERATIONS.
(Cubic Meters)
B. ESTIMATED DAILY CAPACITY REQUIREMENT OF THE TERMINAL/PORT TO RECEIVE
NLS RESIDUES RESULTING FROM PREWASH OPERATIONS:
(Cubic Meters)
C. CAN THE RECEPTION FACILITY RECEIVE ALL NLS RESIDUES RESULTING FROM PREWASH
OPERATIONS FROM SHIPS WITHIN 10 HOURS AFTER NLS RESIDUE TRANSFER BEGINS?
(Yes, No, N/A)
D. WILL THE RECEPTION FACILITIES FOR NLS RESIDUES BE PROVIDED WITHIN 24 HOURS
AFTER NOTIFICATION BY A VESSEL INDICATING THE NEED FOR RECEPTION FACILITIES?
(Yes, No, N/A)
E. WILL THE RECEPTION FACILITIES BE PROVIDED AT THE UNLOADING TERMINAL/PORT?
F. DOES THE RECEPTION FACILITY HOLD EACH FEDERAL, STATE, AND LOCAL PERMIT AND
LICENSE REQUIRED BY ENVIRONMENTAL LAWS AND REGULATIONS CONCERNING NLS
RESIDUES?
G. CAN THE RECEPTION FACILITY RECEIVE ALL NLS RESIDUES PRIOR TO THE SHIP LEAVING
THE SHIP REPAIR YARD?

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(Yes, No, N/A)
(Yes, No, N/A)
(Yes, No, N/A)

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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 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 II 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 Noxious Liquid Substance (NLS) Residues and Mixtures Containing NLS Residues 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 NLS residue from oceangoing ships.
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 release of NLS
Residues or Mixtures Containing NLS, 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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