Vessel General Permit for Discharges Incidental to the Normal Operation of Vessels (VGP)

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Appendix K – Permit Authorization and Record of Inspection Form (PARI)
(for vessels which need not complete NOIs)
VGP Authorization and Record of Inspection (PARI) Form
I. Vessel Owner/Operator Information
Vessel Owner/Operator

Phone

Address and Email Address
II. Vessel Information
Vessel Name
Vessel Identifier

Vessel Type
Registered number/operating number

IMO number

III. Owner/Operator Acknowledgement
By signing this form, I acknowledge that I have read and am familiar with the VGP and that I am
implementing all permit requirements contained in the VGP.
IV. Certification Information
I certify under penalty of law that this document and all attachments were prepared under my direction or
supervision in accordance with a system designed to assure that qualified personnel properly gathered and
evaluated the information contained therein. Based on my inquiry of the person or persons who manage the
system, or those persons directly responsible for gathering the information, the information contained is, to the
best of my knowledge and belief, true, accurate, and complete. I have no personal knowledge that the
information submitted is other than true, accurate, and complete. I am aware that there are significant penalties
for submitting false information, including the possibility of fine and imprisonment for knowing violations.
Signature and Date
V. Annual Inspections by Year
A. 2014
I certify that I have completed an annual inspection for 2014 in accordance with Part 4.1.3 of the VGP.
Signature and Date
B. 2015
I certify that I have completed an annual inspection for 2015 in accordance with Part 4.1.3 of the VGP.
Signature and Date
C. 2016
I certify that I have completed an annual inspection for 2016 in accordance with Part 4.1.3 of the VGP.
Signature and Date
D. 2017
I certify that I have completed an annual inspection for 2017 in accordance with Part 4.1.3 of the VGP.
Signature and Date
E. 2018
I certify that I have completed an annual inspection for 2018 in accordance with Part 4.1.3 of the VGP.
Signature and Date