BALLAST WATER REPORTING FORM

(BALAST SUYU RAPORLAMA FORMU)

TO BE PROVIDED TO HARBOUR MASTERS BEFORE ARRIVAL
(LMAN BAKANINA LMANA GRMEDEN NCE GNDERLECEKTR)

1. VESSEL INFORMATION (GEM BLGLER) 2. BALLAST WATER (BALAST)

Specify Units:m3, MT, LT (Birimleri m3, MT,LT cinsinden belirtin)

Vessel name (Gemi Ad): Type(Gemi Tipi): Total Ballast Water on Board (Gemide mevcut balast miktar):

Owner (Gemi Sahibi): GT Total Ballast Water Capacity (Geminin balast alma kapasitesi):

Flag (Bayra): Arrival Date (Var Tarihi): 3. BALLAST WATER TANKS (BALAST TANKLARI)

Last Port and Country: Arrival Port (Var Liman): Balast Water Management Plan On board? (Gemide Balast Ynetim Plan varm?) .....Yes(Evet) .....No(Hayr)

(Geldii Liman ve lke) IMO No: Total No of Ballast Tanks On Board (Gemide bulunan balast tank says)

Next Port and Country: Call Sign (ar areti) No Of Tanks In Ballast (Balast dolu tank says)

(Gidecei Liman ve lke) Agent(Acenta): No Of Tanks Exchanged (Balast deiimi yaplm tank says)

No Of Tanks Not Exchanged (Balast deiimi yaplmam tank says)

4. BALLAST WATER HISTORY (BALAST KAYIT)
Record All Tanks That Will Be Deballasted In The Port State Of Arrival; If None Go To 5 (Var limannda boaltlacak tm balast tanklar kayt altna alnacaktr. Eer yoksa 5'e gein)

Tanks/Holds (list
multiple sources/tank BW SOURCE (BALAST ALIMI) BW EXCHANGE (BALAST DEM) BW DISCHARGE (BALAST BASIMI)
separately)
Tanklar/Ambarlar
(tek-tek belirtilecek) Date (DD/MM/YY) Port or Lat. Long. Volume Temp Date (DD/MM/YY) End point Lat. Long. Volume Salinity Date (DD/MM/YY) Port or Lat. Long. Volume Salinity
Tarih (GG/AA/YY) Liman veya Koordinat Miktar Scaklk Tarih (GG/AA/YY) Liman veya Koordinat Miktar Tuzluluk Tarih (GG/AA/YY) Liman veya Koordinat Miktar Tuzluluk

Ballast Water Tank Codes: Forepeak=FP, Aftpeak=AP, Double Bottom=DB, Wing=WT, Topside=TS, Cargo Hold=CH, Other=O
Balast Tank Kodlar:Bapik=FP,kpik=AP, diptank=DB, Asmatank=WT, Yantank=TS, Ambar=CH, dier =O

5. IMO BALLAST WATER GUIDELINES ON BOARD (RES.A 20/868)? (Gemide RES. A20/868 simgeli IMO Rehberi Varm?).....Yes(Evet) .....No(Hayr)
RESPONSBLE OFFICER'S NAME AND TITLE (PRINTED) AND SIGNATURE
(Sorumlu Personelin smi nvan ve mzas) __________________________________________________________________