Completion Instructions For Ballast Water Reporting Form
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The Coast Guard estimates that the average burden for this report is 35 minutes. You may submit any comments concerning the accuracy of this burden estimate or any suggestions for reducing the burden to: Commandant (G-PS0-4)), U.S. Coast Guard, 2100 2nd St, SW, Washington, D.C. 20593-0001 or Office of Management and Budget, Paperwork Reduction Project (1625-0069), Washington, DC 20593.
(Please write in English and PRINT legibly.)
Is this an Amended Ballast Reporting Form? Check Yes or No. Amendments should be submitted if there are any differences between actual ballast discharges and discharge information reported in a prior form. Please mark "Yes" if this form amends a previously submitted ballast reporting form.
SECTION 1. VESSEL INFORMATION
Vessel Name: Print the name of the vessel clearly.
IMO Number: Fill in identification number of the vessel used by the International Maritime Organization.
Owner: Write in the name of the registered owner(s) of the vessel. If under charter, enter Operator name.
Type: List specific vessel type. Use the following abbreviations: bulk (bc), roro (rr), container (cs), tanker (ts), passenger (pa), oil/bulk ore (ob), general cargo (gc), reefer (rf). Write out any additional vessel types.
GT: What is the Gross Tonnage of the vessel?
Call Sign: Write in the official call sign.
Flag: Fill in the full name of the country under whose authority the ship is operating. No abbreviations please.
SECTION 2. VOYAGE INFORMATION
Arrival Port: Write in the name of your United States port or place of destination for this voyage. No abbreviations please.
Arrival Date: Fill in the arrival date to the above port. Please use European date format (DDMMYY).
Agent: List agent used for the Arrival Port.
Last Port: Fill in the last port at which the vessel called. No abbreviations please.
Country of Last Port: Fill in the last country at which the vessel called. No abbreviations please.
Next Port: Fill in the port at which the vessel will call immediately after departing the Arrival Port. No abbreviations please.
Country of Next Port: Fill in the country of "Next Port" at which the vessel will call immediately after departing the Arrival Port. No abbreviations please.
SECTION 3. BALLAST WATER
Total Ballast Water on Board:
Volume: What was the total volume of ballast water on board upon arrival into the "Arrival Port" listed in Section 2? Do not count potable water.
Units: Please include volume units (m3, MT, LT, ST).
Number of Tanks in Ballast: Count the number of ballast tanks and holds with ballast as vessel arrives into the "Arrival Port" listed in Section 2.
Total Ballast Water Capacity:
Volume: What is the maximum volume of ballast water used when no cargo is on board?
Units: Please include volume units (m3, MT, LT, ST).
Total Number of Tanks on Ship: Count all tanks and holds that can carry ballast water (do not include tanks that carry potable water).
SECTION 4. BALLAST WATER MANAGEMENT
Total No. of tanks to be discharged: Count only tanks and holds with ballast to be discharged into waters in the port state of arrival or into an approved reception facility. Count all tanks and holds separately (e.g., port and starboard tanks should be counted separately).
Of tanks to be discharged, how many Underwent Exchange: Count all tanks that are to be discharged in the port state of arrival or into an approved reception facility.
Of tanks to be discharged, how many Underwent Alternative Management: Count all tanks that are to be discharged in the port state of arrival or an approved reception facility.
Please specify alternative method(s) used, if any: Specifically, describe methods other than Empty/Refill or Flow-Through used for ballast management.
If no ballast treatment conducted, state reason why not: This applies to all unexchanged tanks and holds being discharged in the port state of arrival or into an approved reception facility.
Ballast Management Plan on board?: Is there a written document on board, specific to your vessel, describing the procedure for ballast management? This should include safety and exchange procedures (usually provided by vessel’s owner or operator). Check Yes or No.
Management Plan implemented?: Do you follow the above management plan? Check Yes or No.
IMO Ballast Water Guidelines on board?: Is there a copy of the International Maritime Organization (IMO) Ballast Water Guidelines on board this vessel (i.e. "Guidelines for the Control and Management of Ship’s Ballast Water to Minimize the Transfer Aquatic Organisms and Pathogens", [Res. A.868(20)])? Check Yes or No.
SECTION 5. BALLAST WATER HISTORY
(Record all tanks to be deballasted in port state of arrival: If none, go to #6)
Tanks/Holds: Please list all tanks and holds that you have discharged or plan to discharge into waters of the United States or into an approved reception facility (write out, or use codes listed below table). Follow each tank across the page listing all source(s), all management events, and all discharge events separately.
List each tank on a separate line. Paired port and starboard tanks with identical ballast water histories may be included on same line. Please use an additional page if necessary, being careful to include ship name, date, and IMO number at the top of each.
For tanks with multiple sources: list 3 largest sources from last 30 days on separate lines. If more than 3 sources, include a 4th line for the respective tank(s) that indicates "Multiple" in port column and list the remaining tank volume not included in the 3 largest sources (i.e. total tank volume minus volume of the 3 largest sources).
-BW SOURCES-
Date: Record date of ballast water uptake. Use European format (DDMMYY).
Port or latitude/longitude: Record location of ballast water uptake. No abbreviations for ports.
Volume: Record total volume of ballast water uptake, with volume units.
Temp: Record water temperature at time of ballast water uptake, in degrees Celsius (include units).
-BW MANAGEMENT PRACTICES-
Date: Date of ballast water management practice. If exchanges occurred over multiple days, list the day when exchanges were completed. Use European format (DDMMYY).
Endpoint or latitude/longitude: Report location of ballast water management practice. If an exchange occurred over an extended distance, list the end point latitude and longitude.
Volume: Report total volume of ballast water moved (i.e., gravitated and pumped into tanks, discharged to reception facility) during management practice, with units.
% Exchange: (Note: for effective flow through exchange, this value should be at least 300%).
Total Volume Added by Empty/Refill or by Flow Through
% Exchange = ----------------------------------------------------------------------- x 100
Capacity of Ballast Tank or Hold
Method: Indicate management method using code (ER = empty/refill, FT = flow through, ALT = alternative method).
Sea Ht. (m): Estimate the sea height in meters at the time of the ballast water exchange if this method was used. (Note: this is the combined height of the wind-seas and swell, and does not refer to water depth).
-BW DISCHARGES-
Date: Date of ballast water discharge. Use European format (DDMMYY).
Port or latitude/longitude: Report location of ballast water discharge. No abbreviations for ports.
Volume: Report volume of ballast water discharged, with units.
Salinity: Document salinity of ballast water at the time of discharge, with units (i.e., specific gravity (sg) or parts per thousand (ppt)).
SECTION 6. TITLE AND SIGNATURE
Responsible officer’s name and title (printed) and signature: Print name and title, include signature. A signature is not necessary on electronic forms.
Annotated Sample Form
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