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pdfOMB Control Number 1625‐0069
Expiration Date: 08/31/2018
BALLAST WATER REPORT
Is this a re‐submission for this arrival (Yes/No)? If yes, please include the NBIC reference number supplied with first submission: __________________________
1. VESSEL INFORMATION
2. VOYAGE INFORMATION
3. BALLAST WATER USAGE AND CAPACITY
Vessel Name:
Arrival Port (Port and COTPZ):
Vessel IMO Number
Arrival Date (DD/MMM/YYYY):
Total Ballast Water on Board
Owner:
Departure Date (DD/MMM/YYYY):
Vessel Type:
Agent Name:
Country of Registry:
Agent e‐mail Address:
Total Ballast Water Capacity
Call Sign:
Last Port (Port and Country):
3
Vessel e‐mail Address:
Volume (m3)
Number of Tanks in Ballast
Total Number of Tanks on Ship
Volume (m )
Next Port (Port and Country):
4. BALLAST WATER HISTORY: Record ONLY those tanks to be discharged in U.S. waters (en route to and at the port or place of arrival). If NONE, leave blank and GO TO #5
TANK
INFORMATION
BW SOURCE
BW MANAGEMENT PRACTICES
BW DISCHARGE
#
Type
Capacity
Date
DD/MMM/YYYY
PORT or
LAT LONG
VOLUME
Date
DD/MMM/YYYY
Start Point
LAT LONG
End Point
LAT LONG
VOLUME
(Exch. only)
METHOD
Date
DD/MMM/YYYY
PORT or
LAT LONG
VOLUME
Comments: ______________________________________________________________________________________________________________________________________
5. Responsible Officer’s Printed Name & Title __________________________________________ Signature ________________________________ Date: ______________
| File Type | application/pdf |
| File Title | Microsoft Word - BWM_VoyageReport_2015_tracked.doc |
| Author | DADuPont |
| File Modified | 2015-09-10 |
| File Created | 2015-09-10 |