FORM S/4
Clasification Society 2024 - Version 9.40
Statutory Documents - IMO Publications and Documents - Resolutions - Marine Environment Protection Committee - Resolution MEPC.357(78) - 2022 Guidelines for Inspection of Anti-Fouling Systems on Ships - (adopted on 10 June 2022) - Annex - 2022 Guidelines for Inspection of Anti-Fouling Systems on Ships - Appendix 1 - Sampling - FORM S/4

FORM S/4

 
         
  RECORD NUMBER      
 

Name of ship

_________________________

IMO number:

_________________________

METHOD 2 ANALYSIS

Case A - Analysis of organotin only

First stage

1. Instrument I.D.: Calibration expire date:
               
2. Sample location (frame & distance from boot topping) Specimen I.D. Sample disc Content of tin (mg/ kg) max min Average
A   A1 ☐ abrasive        
    A2 ☐ metal        
    A3 ☐ others       Average
    A4 ☐ abrasive        
    A5 ☐ metal       mg/kg
    A6 ☐ others       ☐ >2,500 mg/kg
    A7 ☐ abrasive       ☐>3,000 mg/kg
    A8 ☐ metal        
    A9 ☐ others        
B   B1 ☐ abrasive        
    B2 ☐ metal        
    B3 ☐ others       Average
    B4 ☐ abrasive        
    B5 ☐ metal       mg/kg
    B6 ☐ others       ☐ >2,500 mg/kg
    B7 ☐ abrasive       ☐ >3,000 mg/kg
    B8 ☐ metal        
    B9 ☐ others        
C   C1 ☐ abrasive        
    C2 ☐ metal        
    C3 ☐ others       Average
    C4 ☐ abrasive        
    C5 ☐ metal       mg/kg
    C6 ☐ others       ☐ >2,500 mg/kg
    C7 ☐ abrasive       ☐ >3,000 mg/kg
    C8 ☐ metal        
    C9 ☐ others        
D   D1 ☐ abrasive        
    D2 ☐ metal        
    D3 ☐ others       Average
    D4 ☐ abrasive        
    D5 ☐ metal       mg/kg
    D6 ☐ others       ☐ >2,500 mg/kg
    D7 ☐ abrasive       ☐ >3,000 mg/kg
    D8 ☐ metal        
    D9 ☐ others        
3. Results first-stage analysis  
    ☐ ___samples out of___are above
2,500 mg/kg 		☐ Compliant
    ☐ sample(s) ____ is (are) above 3,000 mg/kg ☐ Second stage required
4. Comments
5. Company Name  
          Date  
          Signature  

Second stage

1. Instrument I.D.: Calibration expire date:
               
2. Specimen used (frame & distance from boot topping) Content of tin first stage (XRF analysis) (mg Sn/kg) Content of tin second stage (as organotin) (mg Sn/kg) Compliance
A        
        ☐>2,500 mg/kg
        ☐>3,000 mg/kg
B        
        ☐>2,500 mg/kg
        ☐>3,000 mg/kg
C        
        ☐>2,500 mg/kg
        ☐>3,000 mg/kg
D        
        ☐>2,500 mg/kg
        ☐>3,000 mg/kg
3. Results second stage analysis  
    ☐ ___samples out of___are above
2,500 mg/kg
(dry paint) 		☐ Compliant
    ☐ sample(s) ____ is (are) above 3,000 mg/kg
(dry paint) 		☐ Second stage required
4. Comments
5. Company Name  
          Date  
          Signature  

Case B – Analysis of cybutryne only

Gas chromatography/mass spectrophotometry (GC/MS) analysis for cybutryne determination

1. Instrument I.D.: Calibration expire date:
               
2. Results
of GC-MS analysis 		 
  Average concentration (mg of cybutryne per kg of dry paint)   ☐ Compliant
    ☐ Not compliant
3. Comments
4. Company Name  
        Date  

Case C – Simplified approach to detect organotin and cybutryne

Gas chromatography/mass spectrophotometry (GC/MS) analysis for cybutryne and organotin determination

1. Instrument I.D.: Calibration expire date:
               
2. Results
of GC-MS analysis 		 
  Average concentration of organotin (mg Sn/kg)   ☐ Compliant

☐ Not compliant
  Average concentration of cybutryne (mg of cybutryne per kg of dry paint)   ☐ Compliant

☐ Not compliant
3. Comments
4. Company Name  
        Date  

PORT STATE PARTICULARS

Reporting authority:   District office:  
Address: ___________________________________________________________________________________________________________________________
  ___________________________________________________________________________________________________________________________
Telephone/Fax/ Mobile: ___________________________________________________________________________________________________________________________
E-mail: ___________________________________________________________________________________________________________________________
Name:
___________________________________________________________________________________________________________________________
(duly authorized inspector of reporting authority) ___________________________________________________________________________________________________________________________
Date: ____________________________________ Signature: ____________________________________
Parent topic: Appendix 1 - Sampling
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