Appendix
Clasification Society 2024 - Version 9.40
Statutory Documents - IMO Publications and Documents - Resolutions - Marine Environment Protection Committee - Resolution MEPC.288(71) - 2017 Guidelines for Ballast Water Exchange (G6) - (Adopted on 7 July 2017) - Appendix

Appendix

  EXAMPLE BALLAST WATER REPORTING FORM  
  Date of Submission (DD/MM/YYYY):____________________ Time of Submission (24:00 GST): ____________________ AMENDED FORM: Yes ☐ No☐  
  1. SHIP INFORMATION 2. VOYAGE INFORMATION 3. BALLAST WATER USAGE AND CAPACITY  
  Ship Name: Arrival Port:    
  IMO Number: Arrival Date (DD/MM/YYYY): Total Ballast Water on Board:  
  Owner: Agent: Volume Units No. of Tanks and Holds in Ballast  
  Type: Last Port: Country:   m3    
  GT: Next Port: Country: Total Ballast Water Capacity:  
  Date of Construction (DD/MM/YYYY): Next Port (2): Country: Volume Units Total No. of Ballast Tanks and Holds on Ship  
  Flag: Next Port (3): Country:   m3    
             

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 _________________________________ IMO Number _________________________________ Arrival Date: _________________________________
           
Tanks/Holds List multiple sources/ tanks separately TANK CAPACITY BW SOURCES CURRENT BW MANAGEMENT PRACTICES PROPOSED BW DISCHARGE
DATE DD/MM/YYYY PORT or LAT. LONG. VOLUME (m3) DATE DD/MM/Y YYY Start Point* Lat. & Long. End Point* Lat. & Long. VOLUME Used* (m3) % Exch* METHOD (DM/SM/ FM, T) SALINITY (PSU) DATE DD/MM/YYYY PORT or LAT. LONG. VOLUME (m3) SALINITY (PSU)
                               
                               
                               
                               
                               
                               
                               
                               
                               
                               
                               
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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