1.

Vessels name:

 

2.

Flag State:

 

3.

IMO Number:

 

4.

Call sign:

 

5.

Estimated time of arrival (ETA):

 

6.

Estimated time of departure (ETD):

 

7.

Previous port of call:

 

8.

Next port of call:

 

9.

Last port and date when ship-generated waste was delivered:

 

10.

Are you delivering:

all

some

of your waste into port reception facilities.

11.

Preferred time of waste-delivery:

Date:

Time:

12.

Place of delivering:

 

Type and amount of waste and residues to be delivered and/or remaining on board, and percentage of maximum storage capacity. If delivering all waste complete second row as appropriate. If delivering some waste complete all rows.

Type

Slugde, bilge water

Sewage

Waste to be delivered [m3]

 

 

Maximum dedicated storage capacity [m3]

 

 

Amount of waste retained on board [m3]

 

 

Port at which remaining waste vill be delivered

 

 

Estimated amount of waste to be generated between notification and next port of call [m3]

 

 

13.

Notes:

 

 

 

 

I confirm that:

- The details above are accurate and correct.

- This information may be used for port State control and other inspection purposes.

- There is sufficient dedicated onboard capacity to store all waste generated between notification and the next adequate port at which waste will be delivered.

Date/time:

  

Signature:

  

Email:

  

Phone: