|
1. |
Country |
|
|
|
Name Of port or area |
|
|
|
Location in the port (e.g. berth/terminal/jetty) |
|
|
|
Date of incident |
|
|
2. |
Type and amount of garbage for discharge to facility: |
|
|
|
a. Total amount: |
|
|
|
food waste |
m3 |
|
|
cargo-associated waste |
m3 |
|
|
maintenance waste |
m3 |
|
|
other |
m3 |
|
|
b. Amount not accepted by the facility: |
|
|
|
food waste |
m3 |
|
|
cargo-associated waste |
m3 |
|
|
maintenance waste |
m3 |
|
|
other |
m3 |
|
3. |
Special problems encountered: |
|
|
|
Undue delay |
|
|
|
Inconvenient location of facilities |
|
|
|
Unreasonable charges for use of facilities |
|
|
|
Use of facility not technically possible |
|
|
|
Special national regulations |
|
|
|
Other |
|
|
4. |
Remarks: (e.g. information received from port authorities or operators of reception facilities: reasons given concerning 2 above). |
|
|
5. |
Ships's particulars |
|
|
|
Name of ship |
|
|
|
Owner or operator |
|
|
|
Distinctive number or letters |
|
|
|
Port of registry |
|
|
|
Number of persons on board |
|
|
|
Date of completion of form |
Signature of master |
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