Vessel Name IMO Number Country of Registry Owner/Agent

Arriving Port Arrival Date Last Port of Call Date Departed Last Port

Total Ballast Water Capacity (m³) Total Ballast Water on Board (m³)

Tank Name / Number	Capacity (m³)	Ballast Water Source (Port/Location)	Date Loaded	Volume Loaded (m³)	Ballast Water Exchange/ Treatment	Date Exchanged/ Treated	Volume Exchanged/ Treated (m³)	Method	Ballast Water Discharge Port/Location

Master/ Responsible Officer Name Title Date