Appendix 3 - Standard Format for the Waste Delivery Receipt
Clasification Society 2024 - Version 9.40
Statutory Documents - IMO Publications and Documents - Circulars - Marine Environment Protection Committee - MEPC.1/Circular.834/Rev.1 - Consolidated Guidance for Port Reception Facility Providers and Users (1 March 2018) - Appendix 3 - Standard Format for the Waste Delivery Receipt

Appendix 3 - Standard Format for the Waste Delivery Receipt

 The designated representative of the reception facility provider should provide the following form to the master of a ship that has just delivered wastes/residues.

This form shall be retained on board the ship along with the appropriate Oil Record Book, Cargo Record Book or Garbage Record Book.

1. RECEPTION FACILITY AND PORT PARTICULARS

1.1 Location/Terminal name:
1.2 Reception facility provider(s)
1.3 Treatment facility provider(s) – if different from above:
1.4 Waste/residue Discharge Date and Time from: to

2. SHIP PARTICULARS

2.1 Name of ship: 2.5 Owner or operator:
2.2 IMO number: 2.6 Distinctive number or letters:
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 WASTES/RESIDUES RECEIVED

             
  MARPOL Annex I – Oil Quantity (m3)   MARPOL Annex V – Garbage Quantity (m3)  
  Oily bilge water     A. Plastics    
  Oily residues (sludge)     B. Food wastes    
  Oily tank washings     C. Domestic wastes    
  Dirty ballast water     D. Cooking oil    
  Scale and sludge from tank cleaning     E. Incinerator ashes    
  Other (please specify)     F. Operational wastes    
  MARPOL Annex II – NLS Quantity (m3 /Namefootnote   G. Animal carcasses    
  Category X substance     H. Fishing gear    
  Category Y substance     I. E-waste    
  Category Z substance     J. Cargo residues (non-HME)footnote    
  OS – other substances     K. Cargo residues (HME)footnote    
  MARPOL Annex IV – Sewage Quantity (m3)   MARPOL Annex VI – Air pollution Quantity (m3)  
        Ozone-depleting substances and equipment containing such substances    
        Exhaust gas-cleaning residues    
             
On behalf of the port facility I confirm that the above wastes/residues were delivered.
Signature: ……………………………… Full Name and Company Stamp: …………………………………………
Parent topic: MEPC.1/Circular.834/Rev.1 - Consolidated Guidance for Port Reception Facility Providers and Users (1 March 2018)
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