292 

 It la o«rtlfl«d that the ship is aqidpyed vith a .•••• STataa. 



THIS IS TO CERTIFY 



That the ship hsM been smveyed in accordance with Regulation 4 of 

 Annex I to the International Convention for the Prevention of 

 Pollution fron Ships, 1973 » concerning the prevention of pollution 

 by oil; and. 



That the survey showed that the condition of the construction and 

 equipment of the ship was in all respects satisfactory and that the 

 ship conplies with the applicable requirenents of iinnex I of the 

 said Convention. 



Particulars of requirenents fron which exenption is granted under 

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



This Certificate is valid xmtil 



subject to periodical inspection in accordance v;ith Regulation 4 of 

 Annex I of the said Convention. 



Issued at 



(Place of issue of certificate) 



19 



(Date of issue) (Signature of official issuing 



the certificate and/or seal of 

 issuing authority) 



If signed, the follo\/ing paragraph is to be added: 



The undersigned declares that he is duly authorized by the said 

 Govemnent to issue this Certificate, 



