Ballast Water Reporting Form
Vessel Information
Name of Ship
IMO Number
Flag
Call Sign
Owner
Agent
Voyage Information
Arrival Port
Arrival Date
Departure Port
Departure Date
Ballast Water Summary
Total Ballast Capacity (m³)
Ballast Water on Board (m³)
Ballast Water Tanks
Tank Name/Number
Capacity (m³)
Ballast Water Source Location
Volume Loaded (m³)
Date Loaded
Exchange Method
Volume Exchanged (m³)
Exchange Location
Date Exchanged
Volume Discharged (m³)
Discharge Location
Date Discharged
Flow-through
Sequential
Other
Flow-through
Sequential
Other
Treatment System (if any)
System Installed
Type
Date Operated
Master’s Declaration
Name
Signature
Date