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EXAMPLE BALLAST WATER REPORTING FORM
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Date of Submission
(DD/MM/YYYY):____________________
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Time of Submission (24:00 GST):
____________________
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AMENDED FORM:
Yes ☐ No☐
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1. SHIP INFORMATION
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2. VOYAGE INFORMATION
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3. BALLAST WATER USAGE
AND CAPACITY
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Ship Name:
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Arrival Port:
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IMO Number:
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Arrival Date (DD/MM/YYYY):
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Total Ballast
Water on Board:
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Owner:
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Agent:
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Volume
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Units
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No. of Tanks and Holds in Ballast
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Type:
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Last Port: Country:
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m3
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GT:
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Next Port: Country:
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Total Ballast
Water Capacity:
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Date of Construction (DD/MM/YYYY):
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Next Port (2): Country:
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Volume
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Units
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Total No. of Ballast Tanks and Holds on Ship
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Flag:
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Next Port (3): Country:
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m3
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4. BALLAST WATER MANAGEMENT
Total No. Ballast Water Tanks to be discharged: ______
Of tanks to be discharged, how many: underwent exchange: ______ were treated using a
Ballast Water Management System: ______
Please specify Ballast Water Management System used, if any (Manufacturer,
Model):________________________________________________________
If no Ballast Water Management conducted, state reason why not:
________________________________________________________________________
Approved Ballast Water Management plan on board? Yes ☐ No☐ Management plan
implemented? Yes ☐ No☐
Ballast water record book on board? Yes ☐ No☐
Does ship carry an International Ballast Water Management Certificate: Yes ☐ No☐
- Date of issue (DD/MM/YYYY): ____________________ Expiry Date (DD/MM/YYYY):
____________________
- Authority that issued Certificate: ____________________ Place of issue:
____________________
Date Required to Meet Regulation D-2 (DD/MM/YYYY): ____________________
5. BALLAST WATER HISTORY: RECORD ALL TANKS/ HOLDS containing water taken on board to
control trim, list, draught, stability or stresses of the ship, regardless of
ballast water discharge intentions, on page 2. Note: BW Sources are the last BW
uptakes prior to any Ballast Water Management practices.
6. RESPONSIBLE OFFICER'S NAME AND TITLE:
Ship Name
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_________________________________
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IMO Number
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_________________________________
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Arrival Date:
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_________________________________
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Tanks/Holds
List multiple sources/ tanks separately
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TANK
CAPACITY
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BW
SOURCES
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CURRENT
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BW
MANAGEMENT PRACTICES
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PROPOSED BW DISCHARGE
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DATE DD/MM/YYYY
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PORT or LAT. LONG.
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VOLUME (m3)
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DATE DD/MM/Y YYY
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Start Point* Lat. &
Long.
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End Point* Lat. &
Long.
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VOLUME Used*
(m3)
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% Exch*
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METHOD (DM/SM/ FM, T)
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SALINITY (PSU)
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DATE DD/MM/YYYY
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PORT or LAT. LONG.
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VOLUME (m3)
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SALINITY (PSU)
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Ballast Water Tank Codes: Forepeak = FP, Aftpeak =
AP, Double Bottom = DB, Wing = WT, Topside = TS, Cargo Hold =
CH, Other = O.
Methods: DM= Dilution, SM=Sequential,
FM= Flow Through , T=Treatment.
Complete
columns with (*) only if exchange was
conducted.
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