| Vessel Name: | IMO Number: | ||
| Flag: | Call Sign: | ||
| Voyage Number: | Date of Report: |
| No. | Tank Name / No. | Ballast Water Source (Port/Location) | Date/Time of Uptake | Date/Time of Discharge | Port or Latitude/Longitude of Discharge | Volume Discharged (m³) | Method of Treatment | Reason for Discharge |
|---|---|---|---|---|---|---|---|---|
| 1 | ||||||||
| 2 | ||||||||
| 3 |
| Name: | Rank: | ||
| Signature: | Date: |