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Victorian Ballast Water Report Form

This document is a Victorian Ballast Water Report Form that ships must submit when visiting a Victorian port in Australia. It requires information about the ship, its voyage, last port of call, ballast water status, and any ballast water treatment. The form collects details like the ship name, voyage number, IMO number, estimated time of arrival, and more. It also asks whether the ship has ballast water onboard, where it was taken up, if the ship intends to discharge any in Victoria, and if it conducted approved ballast water exchange or treatment methods. The Chief Officer must sign the completed form which is then faxed to the EPA for review.

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Kuber Nath Pandey
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184 views2 pages

Victorian Ballast Water Report Form

This document is a Victorian Ballast Water Report Form that ships must submit when visiting a Victorian port in Australia. It requires information about the ship, its voyage, last port of call, ballast water status, and any ballast water treatment. The form collects details like the ship name, voyage number, IMO number, estimated time of arrival, and more. It also asks whether the ship has ballast water onboard, where it was taken up, if the ship intends to discharge any in Victoria, and if it conducted approved ballast water exchange or treatment methods. The Chief Officer must sign the completed form which is then faxed to the EPA for review.

Uploaded by

Kuber Nath Pandey
Copyright
© Attribution Non-Commercial (BY-NC)
We take content rights seriously. If you suspect this is your content, claim it here.
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Download as DOC, PDF, TXT or read online on Scribd
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APPENDIX 2: VICTORIAN BALLAST WATER REPORT FORM

VICTORIAN BALLAST WATER REPORT FORM


Ship’s particulars for ship visiting a Victorian Port

1) Vessel Name: ___MV CRONUS LEADER 7) ETA at a Victorian Port: ___:___ Hrs ___/___/______

8) Berth at a Victorian Port: _____________________________


2) Voyage Number: 010
9) Net Tonnage: 18542 MT
3) IMO/Lloyd’s Number: 9464455
10) Number of Cargo Holds/Tanks/Decks: 04/16/13

4) Radio Call Sign: 3FUK 11) Vessel Type: PCTC

5) Last Port of Call: PORT KEMBLA 12) Country of Registry: PANAMA

6) ETD Last Port of Call: ___:___ Hrs ___/___/____

13) Do you have domestic ballast water on board


YES (If YES, where did you take up the ballast water) JEBEL ALI,SINGAPORE

NO (If NO, go to 21 and submit)


14) Do you intend to discharge domestic ballast water in a Victorian Port? YES NO (if No, go to 21)

15) Did you exchange ballast water at sea independent of the AQIS BWDSS Report?
YES (If YES, sign at 21 and submit) NO

16) Have you used the AQIS BWSS to perform a risk assessment on the domestic ballast water to be

discharged into Victorian waters? YES NO (if No, your ballast water will be considered high-risk)

17) If YES, what is the Risk Assessment Number (RAN) assigned to your vessel by the AQIS BWDSS?

RAN:

18) If your AQIS BDWSS result was HIGH will you have completed an approved ballast water
treatment/exchange at sea before arrival in Victoria? YES NO (if No, go to 20)

19) If YES indicate below what approved ballast water treatment/exchange method you used.

Sequential [Empty/refill] Flow Through Dilution Method Other

If other please specify: ________________________________________________________________________

20) If approved treatment was not conducted fully in any of the tanks/holds intended for discharge at a Victorian
Port, please state the reason and contact the EPA as soon as possible:

21) Declared by (Printed Name): KUBER NATH PANDEY_ Signature: ___________________ Rank: CHIEF OFF.

Shipping Agency Name: INCHCAPE________ Shipping Agency Phone No: ________________________

Shipping Agency Fax No: ______________________ Date: _____ / _____ / _____


Fax form to the EPA Ballast Water Officer. Fax No: +613 9695 2520. For further assistance call +613 9695 2547

NOTE: The discharge of high-risk domestic ballast water is prohibited in Victorian


State waters.

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