OMB Control Number 1625-0069

Ballast Water Reporting Form - Page 1

Reporting Form Instructions

Is this an amended Ballast Reporting Form?   Yes   No

1. Vessel Information - Help!
Vessel Name:
IMO number:
Owner:
Vessel Type:
Tonnage:
Call Sign:
Flag:
2. Voyage Information - Help!
Arrival Port:
Arrival Date:
Agent:
Last Port:
Country of Last Port:
Next Port:
Country of Next Port:
3. Ballast Water Usage and Capacity - Help!
Volume Units No. of Tanks
Total Ballast Water on Board:
Total Ballast Water Capacity:
4. Ballast Water Management - Help!
Total number of Ballast Water Tanks to be discharged:
Of tanks to be discharged, how many: Underwent Exchange    Underwent Alternative Management
Please specify alternative method(s) used, if any:
If no ballast treatment conducted, state reason why not:
Ballast management plan on board? Yes No  
Ballast management plan implemented? Yes No  
IMO ballast water guidelines on board [res. A.868(20)]? Yes No