Appendix 3 - Form of the International Certificate on Inventory of Hazardous Materials
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Statutory Documents - IMO Publications and Documents - International Conventions - Hong Kong International Convention For The Safe And Environmentally Sound Recycling of Ships, 2009 - Annex - Regulations for Safe and Environmentally Sound Recycling of Ships - Appendix 3 - Form of the International Certificate on Inventory of Hazardous Materials

Appendix 3 - Form of the International Certificate on Inventory of Hazardous Materials

INTERNATIONAL CERTIFICATE ON INVENTORY OF HAZARDOUS MATERIALS
(Note: This certificate shall be supplemented by Part I of the Inventory of Hazardous Materials)
 
(Official seal) (State)
Issued under the provisions of the Hong Kong International Convention for the Safe and Environmentally Sound Recycling of Ships, 2009 (hereinafter referred to as “the Convention”) under the authority of the Government of
     
  ............................................................................................................................  
  (Full designation of the country)  
     
  by ...............................................................................................................................  
  (Full designation of the person or organization authorized under the provisions of the Convention)  
  Particulars of the Ship    
  Name of Ship    
  Distinctive number or letters    
  Port of Registry    
  Gross tonnage    
  IMO number    
  Name and address of shipowner    
  IMO registered owner identification number    
  IMO company identification number    
  Date of Construction    
 
Particulars of Part I of the Inventory of Hazardous Materials
Part I of the Inventory of Hazardous Materials identification/verification number: ........................
  Note: Part I of the Inventory of Hazardous Materials, as required by regulation 5 of the Annex to the Convention, is an essential part of the International Certificate on Inventory of Hazardous Materials and must always accompany the International Certificate on Inventory of Hazardous Materials. Part I of the Inventory of Hazardous Materials should be compiled on the basis of the standard format shown in the guidelines developed by the Organization.
THIS IS TO CERTIFY:
  1. that the ship has been surveyed in accordance with regulation 10 of the Annex to the Convention; and
  2. that the survey shows that Part I of the Inventory of Hazardous Materials fully complies with the applicable requirements of the Convention.
         
Completion date of survey on which this certificate is based: ................................. (dd/mm/yyyy)
 
This certificate is valid until .................................................................................... (dd/mm/yyyy)
 
Issued at ...........................................................................................................................................
    (Place of issue of certificate)  
         
(dd/mm/yyyy) ............................. ................................................................................................
    (Date of issue) (Signature of duly authorized official issuing the certificate)
       
    (Seal or stamp of the authority, as appropriate)  
         
ENDORSEMENT TO EXTEND THE CERTIFICATE IF VALID FOR LESS THAN FIVE YEARS WHERE REGULATION 11.6 APPLIES footnote
  The ship complies with the relevant provisions of the Convention, and this certificate shall, in accordance with regulation 11.6 of the Annex to the Convention, be accepted as valid until  
  (dd/mm/yyyy): ..............................................    
  Signed: ..........................................................    
    (Signature of duly authorized official)  
     
  Place:    
  Date: (dd/mm/yyyy)    
    (Seal or stamp of the authority, as appropriate)  
         
ENDORSEMENT WHERE THE RENEWAL SURVEY HAS BEEN COMPLETED AND REGULATION 11.7 APPLIESfootnote
  The ship complies with the relevant provisions of the Convention, and this certificate shall, in accordance with regulation 11.7 of the Annex to the Convention, be accepted as valid until  
  (dd/mm/yyyy): ..............................................  
  Signed: ...............................................................................................................................................................................................................  
  (Signature of duly authorized official)  
     
  Place: ..................................................................................................................................................................................................................  
  Date: (dd/mm/yyyy) ...........................................................................................................................................................................................  
     
  (Seal or stamp of the authority, as appropriate)  
ENDORSEMENT TO EXTEND THE VALIDITY OF THE CERTIFICATE UNTIL REACHING THE PORT OF SURVEY OR FOR A PERIOD OF GRACE WHERE REGULATION 11.8 OR 11.9 APPLIESfootnote
  This certificate shall, in accordance with regulation 11.8 or 11.9footnote of the Annex to the Convention, be accepted as valid until (dd/mm/yyyy): ....................................................................................................................................................................................................  
     
  Signed: ...............................................................................................................................................................................................................  
  (Signature of duly authorized official)  
     
  Place: ................................................................................................................................................  
  Date: (dd/mm/yyyy) ..........................................................................................................................  
    (Seal or stamp of the authority, as appropriate)  
     
  ENDORSEMENT FOR ADDITIONAL SURVEYfootnote  
  At an additional survey in accordance with regulation 10 of the Annex to the Convention, the ship was found to comply with the relevant provisions of the Convention.  
  Signed: ..............................................................................................................................................................................................................  
  (Signature of duly authorized official)  
     
  Place: ................................................................................................................................................  
  Date: (dd/mm/yyyy) ..........................................................................................................................  
     
  (Seal or stamp of the authority, as appropriate)  
Parent topic: Annex - Regulations for Safe and Environmentally Sound Recycling of Ships
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