Appendix 1 - Ballast Water Reporting Form
Clasification Society 2024 - Version 9.40
Statutory Documents - IMO Publications and Documents - Resolutions - Assembly - IMO Resolution A.868(20) – Guidelines for the Control and Management of Ships Ballast Water to Minimize the Transfer of Harmful Aquatic Organisms and Pathogens – (Adopted on 27 November 1997) - Annex - Guidelines for the Control and Management of Ships Ballast Water to Minimize the Transfer of Harmful Aquatic Organisms and Pathogens - Appendix 1 - Ballast Water Reporting Form

Appendix 1 - Ballast Water Reporting Form

Ballast water reporting form

(TO BE PROVIDED TO PORT STATE AUTHORITY UPON REQUEST)
1. VESSEL INFORMATION               2. BALLAST WATER  
Vessel Name Type IMO Number: Specify units: m3, MT, LT, ST
Owner: GT: Call Sign: Total Ballast Water on Board:
Flag: Arrival Date: Agent
Last Port and Country: Arrival Port: Total Ballast Water Capacity:
Next Port and Country:
3. Ballast Water Tanks BALLAST WATER MANAGEMENT PLAN ON BOARD? YES ___ NO ___ HAS THIS BEEN IMPLEMENTED YES__NO__
TOTAL NO. OF TANKS ON BOARD_____ NO. OF TANKS IN BALLAST_____ IF NONE IN BALLAST GO TO NO.5.
NO. OF TANKS EXCHANGED_____ NO. OF TANKS NOT EXCHANGED_____        
4. BALLAST WATER HISTORY: RECORD ALL TANKS THAT WILL BE DEBALLASTED IN PORT STATE ARRIVAL; IF NONE GO TO 5.
Tanks/Holds (List multiple sources/tank separately) BW SOURCE BW EXCHANGE circle one: Empty/Refill of Flow Through BW DISCHARGE
DATE DDMMYY Port or LAT. LONG Volume (units) TEMP (units) DATE DDMMYY ENDPOINT LAT. LONG VOLUME (units) % EACH SEA hgt. (m) DATE DDMMYY Port or LAT. LONG VOLUME (units) SALINITY (units)
                           
                           
                           
                           
                           
                           
                           
                           
Ballast Water Tank Codes: Forepeak = FP, Aftpeak = FP, Double Bottom = DB, Wing = WT, Topside = TS, Cargo Hold = CH, O = Other
IF EXCHANGE WERE NOT CONDUCTED, STATE OTHER CONTROL. ACTION(S) TAKEN______________________________________________________________________________
IF NONE STATE REASONS WHY NOT ._______________________________________________
5. IMO BALLAST WATER GUIDELINES ON BOARD (RES.__________)? YES_____ N0______
RESPONSIBLE OFFICERS NAME AND TITLE (PRINTED AND SIGNATURE
Parent topic: Annex - Guidelines for the Control and Management of Ships Ballast Water to Minimize the Transfer of Harmful Aquatic Organisms and Pathogens
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