3. pants

TYPE AND AMOUNT OF WASTE FOR

DISCHARGE TO FACILITY

MARPOL Annex I - Oil

Quantity (m3)

MARPOL Annex V - Garbage

Quantity (m3)

Oily bilge water

Plastic

Oily residues (sludge)

Food waste

Oily tank washings

Domestic waste

Dirty ballast water

Cooking oil

Scale and sludge from tank

cleaning

Incinerator ash

Oily cargo

residues1

Operational waste

Other (specify)

Cargo residues2,

4

MARPOL Annex II - NLS

Quantity (m3)/Name1

Animal carcass (es)

Tank washings containing

category X substances

Fishing gear

Tank washings containing

category Y substances

Other wastes (specify)

Tank washings containing

category Z substances

MARPOL Annex VI - Air pollution

Quantity (m3)

Tank washings containing

other substances

Ozone-depleting substances

and equipment containing such substances

Prewash

Exhaust gas-cleaning residues

Cargo residues containing

category X, Y, Z substances1

Ballast water containing

category X, Y, Z substances

Other (specify)

MARPOL Annex IV - Sewage2

Quantity (m3)

Sewage

Please state below the approximate amount of waste remaining

on board and the percentage of maximum storage capacity. If

delivering all waste on board at this port please strike through

this table and tick the box below. If delivering some or no

waste, please complete all columns.

I confirm that I am delivering all the waste held on the board

of this vessel (as shown above) at this port ⎕

Type

Maximum dedicated storage

capacity m3

Amount of waste retained on

board m3

Port at which remaining waste

will be delivered (if known)

Estimate amount of waste to

be generated between notification and next port of call

m3

MARPOL Annex I - Oil

Oily bilge water

Oily residues (sludges)

Oily tank washings

Dirty ballast water

Scale and sludge from tank

cleaning

Oily cargo

residues2

Other (specify)

MARPOL Annex II - NLS

Tank washings containing

category X substances

Tank washings containing

category Y substances

Tank washings containing

category Z substances

Tank washings containing

other substances

Prewash

Cargo residues containing

category X, Y, Z substance2

Ballast water containing

category X, Y, Z substances

Other (specify)

MARPOL Annex IV -

Sewage3

Sewage

MARPOL Annex V - Garbage

Plastic

Food waste

Domestic waste

Cooking oil

Incinerator ash

Operational waste

Cargo residues 2,

4

Animal carcass (es)

Fishing gear

Other wastes (specify)

1 Indicate the proper shipping name of the NLS

involved.

2 May be estimates.

3 The corresponding boxes do not need to be

completed if it is the intention to make a discharge of sewage at

sea in accordance with Regulation 11 of Annex IV of MARPOL

convention.

4 Indicate the proper shipping name of the dry

cargo.

I confirm that the above details are accurate and correct and

there is sufficient dedicated on-board capacity to store all

waste generated between notification and next port at which waste

will be delivered. ⎕

Date:

Name and

position:

Time:

Signature:

"

Ministru prezidents Valdis

Dombrovskis

Satiksmes ministrs Anrijs

Matīss