Appendix 2 - Standard Format of the Advance Notification Form for Waste Delivery to Port Reception Facilities
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Statutory Documents - IMO Publications and Documents - Circulars - Marine Environment Protection Committee - MEPC.1/Circular.834/Rev.1 - Consolidated Guidance for Port Reception Facility Providers and Users (1 March 2018) - Appendix 2 - Standard Format of the Advance Notification Form for Waste Delivery to Port Reception Facilities

Appendix 2 - Standard Format of the Advance Notification Form for Waste Delivery to Port Reception Facilities

 Notification of the Delivery of Wastes/Residues to: …………….…..…………………….. (enter name of port or terminal) The master of a ship should forward the information below to the designated authority at least 24 hours in advance of arrival or upon departure of the previous port if the voyage is less than 24 hours.

This form should be retained on board the ship along with the appropriate Oil Record Book, Cargo Record Book or Garbage Record Book.

DELIVERY FROM SHIPS (ANF)

1. SHIP PARTICULARS

1.1 Name of ship: 1.5 Owner or operator:
1.2 IMO number: 1.6 Distinctive number or letters:
1.3 Gross tonnage: 1.7 Flag State:
1.4 Type of ship: □ Oil tanker □ Chemical tanker □ Bulk carrier □ Container
□ Other cargo ship □ Passenger ship □ Ro-ro □ Other (specify)

2. PORT AND VOYAGE PARTICULARS

2.1 Location/Terminal name and POC: 2.6 Last Port where wastes/residues were delivered:
2.2 Arrival Date and Time: 2.7 Date of Last Delivery:
2.3 Departure Date and Time: 2.8 Next Port of Delivery (if known):
2.4 Last Port and Country: 2.9 Person submitting this form is (if other than the master):
2.5 Next Port and Country (if known):

3. TYPE AND AMOUNT OF WASTES/RESIDUES FOR DISCHARGE TO FACILITY

             
  MARPOL Annex I – Oil Quantity (m3)   MARPOL Annex V – Garbage Quantity (m3)  
  Oily bilge water     A. Plastics    
  Oily residues (sludge)     B. Food wastes    
  Oily tank washings     C. Domestic wastes    
  Dirty ballast water     D. Cooking oil    
  Scale and sludge from tank cleaning     E. Incinerator ashes    
  Other (please specify)     F. Operational wastes    
  MARPOL Annex II – NLS Quantity (m3 /Namefootnote   G. Animal carcasses    
  Category X substance     H. Fishing gear    
  Category Y substance     I. E-waste    
  Category Z substance     J. Cargo residues (non-HME)footnote    
  OS – other substances     K. Cargo residues (HME)footnote    
  MARPOL Annex IV – Sewage Quantity (m3)   MARPOL Annex VI – Air pollution Quantity (m3)  
        Ozone-depleting substances and equipment containing such substances    
        Exhaust gas-cleaning residues    
             
Name of ship: IMO Number:

 Please state below the approximate amount of wastes/residues remaining on board and the percentage of maximum storage capacity. If delivering all wastes/residues on board at this port please strike through this table and tick the box below. If delivering some or no waste/residue, please complete all columns.

I confirm that I am delivering all the wastes/residues held on board this vessel (as shown on page 1) at this port

Type Maximum dedicated storage capacity (m3) Amount of wastes/residues retained on board (m3) Port at which remaining wastes/residues will be delivered (if known) Estimate amount of wastes/residues to be generated between notification and next port of call (m3)
MARPOL Annex I – Oil
Oily bilge water        
Oily residues (sludge)        
Oily tank washings        
Dirty ballast water        
Scale and sludge from tank cleaning        
Other (please specify)        
MARPOL Annex II-NLSfootnote
Category X substance        
Category Y substance        
Category Z substance        
OS – other substances        
MARPOL Annex IV-Sewage
Sewage        
MARPOL Annex V- Garbage
A. Plastics        
B. Food wastes        
C. Domestic wastes        
D. Cooking oil        
E. Incinerator ashes        
F. Operational wastes        
G. Animal carcasses        
H. Fishing gear        
I. E-waste        
J. Cargo residues (non-HME) footnote        
K. Cargo residues (HME)footnote        
MARPOL Annex VI-Air pollution
Ozone-depleting substances and equipment containing such substances        
Exhaust gas-cleaning residues        
Date: .................................................. Name and Position: .................................................................................
Time: ................................................. Signature: ................................................................................................
Parent topic: MEPC.1/Circular.834/Rev.1 - Consolidated Guidance for Port Reception Facility Providers and Users (1 March 2018)
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