CG-5662 Ballast Water Reporting Form - Online

NBIC: Ballast Water Reporting Form -- Page 1

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OMB Control Number 1625-0069
Exp. Date: 05/31/2015

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:

Fill in vessel information from IMO number
Owner:
Vessel Type:
Tonnage:
Call Sign:
Flag:

2. Voyage Information - Help!
Arrival Port:
Arrival Date:

Day

Mon

Year

Agent:
Last Port:
Country of Last Port:
Next Port:
Country of Next Port:

3. Ballast Water Usage and Capacity - Help!
No. of
Volume
Units
Tanks
Total Ballast Water on
Board:

m3

Total Ballast Water
Capacity:

m3

4. Ballast Water Management - Help!
Total number
of Ballast
Water Tanks

http://invasions.si.edu/cgi/bwform

05/17/2012

NBIC: Ballast Water Reporting Form -- Page 1
to be
discharged:
Of tanks to be
discharged, Underwent Exchange
how many:
Please specify
alternative
method(s)
used, if any:
If no ballast
treatment
conducted,
state reason
why not:
Ballast
management
plan on
board?

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Underwent Alternative Management

Yes

No

Ballast
management
plan
implemented?

Yes

No

IMO ballast
water
guidelines on
board [res.
A.868(20)]?

Yes

No

Submit page 1
Contact us: nbic@ballastreport.org

http://invasions.si.edu/cgi/bwform

05/17/2012