ANNEX 3

1. PORT RECEPTION FACILITY AND PORT PARTICULARS

1.1. Location/terminal name:

1.2. Port reception facility provider(s):

1.3. Treatment facility provider(s) – if different from above:

1.4. Waste delivery date and time from: to:

2. SHIP PARTICULARS

2.1. Name of the ship:

2.5. Owner or operator:

2.2. IMO number:

2.6. Distinctive number or letters:

MMSI (Maritime Mobile Service Identity) number:

2.3. Gross tonnage:

2.7. Flag State:

2.4. Type of ship:

Oil tanker

Chemical tanker

Bulk carrier

Container

Other cargo ship

Passenger ship

Ro-ro

Other (specify)

3. TYPE AND AMOUNT OF WASTE RECEIVED

MARPOL Annex I – Oil

Quantity (m3)

MARPOL Annex V – Garbage

Quantity (m3)

Oily bilge water

A. Plastics

Oily residues (sludge)

B. Food waste

Oily tank washings

C. Domestic waste (e.g. paper products, rags, glass, metal, bottles, crockery, etc.)

Dirty ballast water

D. Cooking oil

Scale and sludge from tank cleaning

E. Incinerator ashes

Other (please specify)

F. Operational waste

MARPOL Annex II – NOXIOUS LIQUID SUBSTANCES (NLS)

Quantity (m3)/Name (1)

G. Animal carcass(es)

Category X substance

H. Fishing gear

Category Y substance

I. E-waste

J. Cargo residues (2) (Harmful to the Marine Environment – HME)

K. Cargo residues (2) (non-HME)

MARPOL Annex VI – Air Pollution related

Quantity (m3)

Category Z substance

Ozone-depleting substances and equipment containing such substances

OS – other substance

Exhaust gas-cleaning residues

MARPOL Annex IV – Sewage

Quantity (m3)

Other waste, not covered by MARPOL

Quantity (m3)

Passively fished waste

(1) Indicate the proper shipping name of the NLS involved.

(2) Indicate the proper shipping name of the dry cargo.

(1)

(2)

(2)