595 



(li) Accidental or other exceptional discharge: 



41. Date and time of occurrence : 



42. Place or position of ship at time of occurrence : 



43. Approximate quantity, name and category of substance : 



44. Circumstances of discharge or escape and general remarks. 

 . Signature of Master 



Appendix V 



Form of Certificate 



INTERNATIONAL POLLUTION PRE\rENTI0N CERTIFICATE FOR THE CARRIAGE 

 OF NOXIOUS LIQUID SUBSTANCES IN BULK (1973) 



(Note. — This Certificate shall be supplemented in the case of a 

 chemical tanker by the certificate required pursuant to the provisions 

 of Regulation 13(3) of Annex II of the Convention.) 



(Official Seal) 



Issued under the provisions of the International Convention for the 

 Prevention of Pollution from Ships, 1973, under the authority of 

 the Government of : 



(Full official designation of State) 



by 



(Full official designation of the competent person or organization authorized under 

 the provisions of the International Convention for the Prevention of Pollution 

 from Ships, 1973) 



ISTame of ship : 



Distinctive number or letter : 

 Port of registry : 

 Gross tonnage : 



This is to certify : 



1. That the ship has been surveyed in accordance with the provisions 

 of Regulation 10 of Annex II of the Convention ; 



2. That the survey showed that the design, construction and equip- 

 ment of the ship are such as to minimize the uncontrolled discharge 

 into the sea of noxious liquid substances ; 



3. That the following arrangements and procedures have been 

 approved by the Administration in connexion with the implementa- 

 tion of Regulation 5 of Annex II of the Convention: 



(Continued on the annexed signed and dated sheet (s) ) 



This certificate is valid, until the day of 



19 , subject to intermediate surveys at intervals of 



Issued at 



(Place of Issue of Certificate) 



19 



(Signature of duly authorized 

 official issuing the Certificate) 



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



