567 



Name of ship : 



Distinctive number or letter : 



Port of registry : 



Gross tonnage : 



Type of ship : 



Oil Tanker, including combination carrier [^] 



Asphalt carrier [^] 



Ship other than an oil tanker with cargo tanks coming under 

 Regulation 2(2) [^] 



Ship other than any of the above [^] 

 New/existing ship [^] 



Date of building or major conversion contract: . 



Date on which keel was laid or ship was in a similar stage of con- 

 struction or on which major conversion was commenced: , 



Date of delivery or completion of major conversion : 



Part A— All Ships : 



The ship is equipped with : 



For ships of 400 tons gross tonnage and above : 



(a) oily water separating equipment [^] (capable of producing 

 the effluent witii oil content not exceeding 100 parts per million) 

 or 



(b) an oil filtering system ['] (capable of producing the effluent 

 with content not exceeding 100 parts per million) 



For ships of 10,000 tons gross tonnage and above : 



(c) an oil discharge monitoring and control system [^] or (addi- 

 tional to (a) or (b) above) 



(d) oily water separating equipment and an oil filtering sys- 

 tem [^] (capable of producing the effluent with oil content not ex- 

 ceeding 15 parts per million) in lieu of (a) or (b) above. 



Particulars of requirements from which exemption is granted under 

 Regulation 2(2) and 2 (4) (a) of Annex I of the Convention : 



Remarks : 

 Part B— Oil Tanker [^ ^J 



Deadweight metric tons. Length of ship 



metres 



It is certified that this ship is : 



(a) required to be constructed according to and complies 

 with [1] 



(b) not required to be constructed according to [^] 



(c) not required to be constructed according to, but complin 

 with ['] 



the requirements of Regulation 24 of Annex I of the Convention. 



The Capacity of segregated ballast tanks is cubic metres 



and complies with the requirements of Regulation 13 of Annex I of 

 the Convention. 



1 Delete as appropriate. 



2 This part should be completed for oil tankers including combination carrier» anA 

 asphalt carriers, and those entries which are applicable should be completed for sMpc 

 other than oil tankers which are constructed and utilized to carry oil in bulk ®f an 

 agzreaate capacity of 200 cubic metres or above. 



3 This page need not be reproduced on a Certificate issued to any ship other than tbose 

 referred to in footnote 1. 



