568 



The segregated ballast is distributed as follows : 

 Tank: 

 Quantity : 



This is to certify : 



That the ship has been surveyed in accordance with Regulation 4 

 of Annex I to the International Convention for the Prevention of 

 Pollution from Ships, 1973, concerning the prevention of pollution by 

 oil ; and 



That the survey shows that the structure, equipment, fittings ar- 

 rangement and material of the ship and the condition thereof is in all 

 respects satisfactory and that the ship complies with the applicable 

 requirements of Annex I of the Convention. 



This Certificate is valid until 



subject to intermediate survey (s) at intervals of 



Issued at: (place of issue of Certificate) 



.Date : 19 



(Signature of duly authorized official issuing 

 . ^ _ the Certificate) 



(Seal or stamp of the issuing Authority, as appropriate) 

 Endorsement for existing sliifs [^] 



This is to certify that this ship has been so equipped as to comply 

 with the requirements of the International Convention for the Pre- 

 vention of Pollution from Ships, 1973 as relating to existing ships 

 three years from the coming into force of the Convention. 



Signed 



(Signature of duly authorized official) 



Place of endorsement 



Date of endorsement .^_ 



(Seal or stamp of the Authority, as appropriate) 



Intermediate survey 



This is to certify that at an Intermediate survey required by Eegu- 

 lation 4(1) (c) of Annex I of the Convention, this ship and the condi- 

 tion thereof is found to comply with the relevant provisions of the 

 Convention. 



Signed ^^_„„»^ — ^--- 



(Signature of duly authorized official) 

 Place 



Date 



(Seal or stamp of the Authority, as appropriate) 



Signed 



(Signature of duly authorized official) 



Place 



Date 



(Seal or stamp of the Authority, as appropriate) 

 Under the provisions of Regulation 8(2) and (4) of Annex I of the 

 Convention the validity of this Certificate is extended until 



1 This entry need not be reproduced on a Certificate other than the first Certificate 

 Issued to any ship. 



