Ballast Water Exchange Report Form

Vessel Information

Vessel Name IMO Number Flag Voyage Number

Exchange Summary

Exchange Date Exchange Method Sequential Flow-through Dilution Location of Exchange (Latitude/Longitude) Water Depth (meters) Distance from Nearest Land (nautical miles)

Tanks Exchanged

Tank Name/Number	Capacity (m³)	Ballast Water Volume Exchanged (m³)	Start Time	End Time

Remarks

Name of Officer in Charge Signature Date