Appendix 1 – Statement of Compliance for a Prototype Ballast Water Treatment Technology
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Statutory Documents - IMO Publications and Documents - Resolutions - Marine Environment Protection Committee - Resolution MEPC.140(54) – Guidelines for Approval and Oversight of Prototype Ballast Water Treatment Technology Programmes (G10) – (Adopted on 24 March 2006) - Annex – Guidelines for Approval and Oversight of Prototype Ballast Water Treatment Technology Programmes (G10) - Appendix 1 – Statement of Compliance for a Prototype Ballast Water Treatment Technology

Appendix 1 – Statement of Compliance for a Prototype Ballast Water Treatment Technology

(Official seal)
Issued under the provisions of
GUIDELINES FOR APPROVAL AND OVERSIGHT OF PROTOTYPE BALLAST WATER TREATMENT TECHNOLOGY PROGRAMMES (G10)
(Resolution MEPC.140(54)),
under the authority of the Government of (full designation of country)
by (full designation of the competent person or organization recognized by the Administration)
Particulars of ship
Name of ship
IMO Numberfootnote
Distinctive number or letters
Port of registry
Gross tonnage
Ballast Water Capacity, Volume and Flow Rates
Date on which keel was laid or ship was at a similar stage of construction or, (in the case of a converted ship) date on which conversion was commenced
Date by which the ship is required to comply with regulation D-2
Date on which the prototype ballast water treatment system was installed
Name and address of prototype ballast water treatment technology manufacturer
Trade name of technology
Serial number or other identifying marking
Name of Active Substance and details of Basic Approval
Brief description of the prototype technology
 
THIS IS TO CERTIFY:
1. That the ship has a prototype ballast water treatment system which is subject to a programme approved in accordance with regulation D-4 by the Government of (insert Government title) on (insert date of approval of programme).
2. That the prototype ballast water treatment technology installation has been surveyed in accordance with Section 4 of the annex to resolution MEPC.140(54).
3. A copy of the approved programme is on board the ship together with equipment, operations and maintenance manuals for the prototype ballast water treatment technology.
This Statement is valid until (date)
  (Place of issue of Statement)
  (Date of issue)
  Signature of authorized official issuing the Statement
    Seal or stamp of the authority, as appropriate
Parent topic: Annex – Guidelines for Approval and Oversight of Prototype Ballast Water Treatment Technology Programmes (G10)
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