| Ship Name: | |
| IMO Number: | |
| Voyage No.: | |
| Period Covered: |
| Date & Time | Position (Lat/Long) | Method of Disposal (Discharge at sea/Reception facility/Other) | Quantity Discharged (m³) | Receiving Facility (if applicable) | Remarks | Signature of Officer in Charge |
|---|---|---|---|---|---|---|
| Chief Engineer's Name: | |
| Date: | |
| Signature: |