Port Reception Facility Waste Delivery Note
1. Ship particulars
Ship Name
IMO Number
Call Sign
Port of Registry
Gross Tonnage
Type of Ship
Owner or Operator
2. Port and facility
Port
Facility
Date of Arrival
Date of Delivery
3. Waste information
Type of Waste
Waste to be delivered (m³)
Waste retained on board (m³)
Waste previously delivered (last port)
Oily waste (MARPOL Annex I)
Sewage (MARPOL Annex IV)
Garbage (MARPOL Annex V)
Noxious Liquid Substances (Annex II)
Other (specify)
4. Additional information
Ship's Representative (Name & Signature)
Date
Port Reception Facility (Name & Signature)
Date