| Date | Time | ||
|---|---|---|---|
| Ship Name | IMO Number | ||
| Voyage Number | Port of Departure | ||
| Port of Arrival | Ballast Tank(s) Exchanged | ||
| Position (Latitude/Longitude) | |||
| Start of Exchange (Date/Time) | Completion of Exchange (Date/Time) | ||
| Method Used (Flow Through, Empty/Refill, Dilution) | |||
| Volume Exchanged (m³) | Percentage Exchanged (%) | ||
| Officer in Charge (Name/Rank) | Signature | ||
| Remarks | |||