Appendix

BALLAST WATER CONTROL REPORT FORM

(To be completed by ship’s master prior to arrival and provided to port State Authority upon request)

NAME OF SHIP:	.................................................
PORT OF REGISTRY:	.................................................
OFFICIAL NO. OR CALL SIGN:	.................................................
OWNERS/OPERATORS:	.................................................
AGENT:	.................................................

IMO GUIDELINES CARRIED?

Yes

No

CONTROL ACTION TAKEN?- Non-release of ballast

Ballast water exchange
Ballast water management practices
Use of shore reception facilities
Other (specify)..................................
...........................................................
Nil

Information on Ballast Water Being Carried

Tank Location	Quantity (tons)	Geographic origin of carried ballast		Salinity of original sample (specific gravity)	Intended discharge port		If exchanged, where was ballast loaded?		Salinity of reballasted sample (specific gravity)	Controls used where ballast not exchanged
		Lat.	Long.		Place	Date	Lat.	Long.
FOREPEAK
AFT PEAK
DOUBLE
BOTTOM
WING TANKS
SIDE TANKS
DEEP TANKS
CARGO HOLDS
OTHER (SPECIFY)

MASTER’S NAME:.................................	MASTER’S SIGNATURE:...........................
(PLEASE PRINT)
DATE:..........................................	PORT LOCATION:................................