APPENDIX 1

ADVANCE NOTIFICATION FORM

FOR WASTE DELIVERY TO PORT RECEPTION FACILITIES
Notification of the Delivery of Waste to: …KINGSTON…… (enter name of port or terminal)
The master of a ship should forward the information below to the designated authority at least 24 hours in advance of arrival or upon
departure of the previous port if the voyage is less than 24 hours
This form shall be retained on board the vessel along with the appropriate Oil RB, or Garbage RB

DELIVERY FROM SHIPS

1. SHIP PARTICULARS

1.1 Name of ship: CFS PALAMEDES 1.5 Owner or operator: CFS Agent: PEREZ Y CIA
1.2 IMO number: 9322841 1.6 Distinctive number or letters: 6YRJ2
1.3 Gross tonnage: 7578 1.7 Flag State: MONTEGO BAY / JAMAICA

1.4 Type of ship: 􀂅 Oil tanker 􀂅 Chemical tanker 􀂅 Bulk carrier 􀂅 Container
􀂅 Other cargo ship 􀂅 Passenger ship 􀂅 Ro-ro 􀂅 Other (specify)

2. PORT AND VOYAGE PARTICULARS

2.6 Last Port where waste was delivered:

2.1 Location/Terminal name and POC: KINGSTON / JAMAICA
Kingston / Jamaica

2.2 Arrival Date and Time: 22.03.2017 / 0100 2.7 Date of Last Delivery: 06.02.2017

2.3 Departure Date and Time: 22.03.2017/ 1800 2.8 Next Port of delivery (if known):

2.4 Last Port and Country: Guanta / Venezuela 2.9 Person submitting this form is (if other than the master):
MASTER / YAKACICLI KEREM
2.5 Next Port and Country (if known): Manzanillo /Panama

3. TYPE AND AMOUNT OF WASTE FOR DISCHARGE TO FACILITY

MARPOL Annex I – Oil Quantity (m3) MARPOL Annex V – Garbage Quantity (m3)

Oily bilge water NIL Plastic 1.3

Floating dunnage, lining, or packing NIL
Oily residues (sludge)
material
Oily tank washings NIL Ground-down paper products, rags, 2.4
glass, metal, bottles, crockery etc.
Dirty ballast water NIL
Cargo residues2, paper products, rags, NIL
Scale and sludge from tank cleaning NIL glass, metal, bottles, crockery, etc.
Food waste NIL
Other (please specify) Dirty oil
Please state below the approximate amount of waste Incinerator ash NIL
and residues remaining on board and the percentage Other wastes (specify) (Operational) 1.3
of maximum storage capacity. If delivering all waste
on board at this port please strike through this table and tick the box below. If delivering some or no waste, please
complete all columns.
Name of ship: CFS PALAMEDES IMO Number:9322841

1
 I confirm that I am delivering all the waste held on board this vessel (as shown on page 1) at this port □
Port at which Estimate amount of
Maximum dedicated Amount of waste remaining waste will waste to be generated
Type
storage capacity m3 retained on board m3 be delivered (if between notification and
known) next port of call m3
MARPOL Annex I – Oil
Oily bilge water N/A N/A N/A N/A

Oily residues (sludges) N/A N/A - -

Oily tank washings N/A N/A N/A N/A

Dirty ballast water N/A N/A N/A N/A

Scale and sludge from N/A N/A N/A N/A

tank cleaning

Other: Dirty Oil N/A N/A - -

MARPOL Annex V – Garbage

Plastic 1.3 cbm - N/A 0.1

Floating dunnage, lining - - N/A

or packing material

Ground paper products, 2.4 cbm - N/A 0.2

rags, glass, metal, bottles,
crockery

Cargo residues, paper - - N/A

products, rags, glass,
metal bottles, crockery

Food waste NIL - N/A

Incinerator ash - - N/A

Other wastes (specify) 1.3 cbm - N/A 0.1

OPERATIONAL

Date: 18.03.2017.................................. Name and Position: CHF OFF / FLOREZ ERNESTO

Time: 1500 LT...................................... Signature: ............................................................................................................

4. WASTE CONTRACTOR AND END USERS PARTICULARS

4.1 Name of Waste Contractor: 4.3 Name of End User

4.2 Permit No. 4.4 Permit No. Distinctive number or letters:
4.3 Type of Equipment : 􀂅 tank wagon Barge
􀂅 Other ( Please state) …….…………

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 APPENDIX 2

STANDARD FORMAT FOR THE WASTE DELIVERY RECEIPT

FOLLOWING A SHIP’S USE OF PORT RECEPTION FACILITIES (MEPC.1/Circ.645)

The designated representative of the reception facility provider should provide the following form to the master of a ship that has just
delivered waste.
This form should be retained on board the vessel along with the appropriate Oil RB, or Garbage RB

1. RECEPTION FACILITY AND PORT PARTICULARS

1.1 Location/Terminal name:

1.2 Reception facility provider(s):

1.3 Treatment facility provider(s) – if different from above:

1.4 Waste Discharge Date and Time from: to

QUARANTINE OFFICER’S REMARKS:
__________________________________________________________________________________________

__________________________________________________________________________________________

Date and time: ...................................................... Signature: ............................................................................................................

2. SHIP PARTICULARS
2.1 Name of ship: CFS PALAMEDES 2.5 Owner or operator: CFS Agent MTS
2.2 IMO number: 9322841 2.6 Distinctive number or letters: 6YRJ2
2.3 Gross tonnage:7578 2.7 Flag State: MONTEGO BAY/JAMAICA

2.4 Type of ship: 􀂅 Oil tanker 􀂅 Chemical tanker 􀂅 Bulk carrier 􀂅 Container
􀂅 Other cargo ship 􀂅 Passenger ship 􀂅 Ro-ro 􀂅 Other (specify)

Date and time: ...................................................... Master’s Signature: .............................................................................................

3. TYPE AND AMOUNT OF WASTE RECEIVED FROM VESSEL

MARPOL Annex V – Garbage Quantity (m3)

Date and time: ..................................................
Plastic 1.3
Permit No: ........................................................
Floating dunnage, lining, or packing NIL
Equipment Used: .............................................. materials
Ground paper products, rags, glass, metal, 2.4
Name of Waste Contractor …………………..
bottles, crockery
Signature........................……………………… Cargo residues, paper products, rags, glass, NIL
metal, bottles, crockery, etc.
MARPOL Annex V – Garbage Quantity (m3)
Food waste NIL
4. TYPE AND AMOUNT OF WASTE Plastic
RECEIVED FROM WASTE CONTRACTOR Incinerator ash NIL
Floating dunnage, lining, or packing
MARPOL Annex I – Oil Quantity (m3) materials
Other wastes (specify) 1.3

Oily bilge water Ground paper products, rags, glass,

metal, bottles, crockery
Oily residues (sludge)
Cargo residues, paper products, rags,
Oily tank washings glass, metal, bottles, crockery, etc.
Dirty ballast water Food waste 3
Scale and sludge from tank cleaning Incinerator ash
Other (please specify) Other wastes (specify)
Date: .................................................................... Permit No: .........................................................................................................

Time: ................................................................... Equipment Used: ................................................................................................

Name of End User……………………………….

Signature : ……………………………………….