Ballast Water Management Report

This "Ballast Water Management Report" is a United States-specific form released by the U.S. Department of Homeland Security on February 22, 2016.

Download the form by clicking the link below, fill it out by hand, and mail it as per the guidelines provided by the department or the applicable legal instructions.

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OMB number 1625-0069
Exp. date: 31-Dec-2018
Ballast Water Management Report
(for use on/after 22-Feb-2016)
Vessel Information
Vessel name
IMO number
ID number
Select country
Country of Registry
Owner/operator
Select vessel type
Type
Gross Tonnage
Select units
Ballast water volume units
Total ballast water capacity
Number of tanks on ship
Ballast water treatment system
Voyage Information
Select state
Arrival port (port and state)
Arrival date
Select country
Last port (port and country)
Select country
Next port (port and country)
Total ballast water on board
Number of tanks in ballast
Alternative BW management conducted, per instructions from COTP:
Certificate of accurate information
By checking this box, I attest to the accuracy of the information provided and that ballast water
management activities were in accordance with the ballast water management plan
required by CFR 151.2050(g).
Responsible Officer's name and title
Select report type
Report type
Submitted by
Contact information
Ballast Water History
On the following page(s), provide the ballast water history for each reported tank.
Submit report via e-mail
Submit report on-line
OMB number 1625-0069
Exp. date: 31-Dec-2018
Ballast Water Management Report
(for use on/after 22-Feb-2016)
Vessel Information
Vessel name
IMO number
ID number
Select country
Country of Registry
Owner/operator
Select vessel type
Type
Gross Tonnage
Select units
Ballast water volume units
Total ballast water capacity
Number of tanks on ship
Ballast water treatment system
Voyage Information
Select state
Arrival port (port and state)
Arrival date
Select country
Last port (port and country)
Select country
Next port (port and country)
Total ballast water on board
Number of tanks in ballast
Alternative BW management conducted, per instructions from COTP:
Certificate of accurate information
By checking this box, I attest to the accuracy of the information provided and that ballast water
management activities were in accordance with the ballast water management plan
required by CFR 151.2050(g).
Responsible Officer's name and title
Select report type
Report type
Submitted by
Contact information
Ballast Water History
On the following page(s), provide the ballast water history for each reported tank.
Submit report via e-mail
Submit report on-line
Ballast Water History
Tank name/number
Tank capacity
Location(s)
Event
Date
(for Management event include Start pt. / End pt.)
Volume
Discharge to US waters
Select event
Select event
Select event
Select event
Select reason
If BW management was *not* conducted for this tank, select one of the following reasons
Tank name/number
Tank capacity
Location(s)
Event
Date
(for Management event include Start pt. / End pt.)
Volume
Discharge to US waters
Select event
Select event
Select event
Select event
Select reason
If BW management was *not* conducted for this tank, select one of the following reasons
Tank name/number
Tank capacity
Location(s)
Event
Date
(for Management event include Start pt. / End pt.)
Volume
Discharge to US waters
Select event
Select event
Select event
Select event
Select reason
If BW management was *not* conducted for this tank, select one of the following reasons
Tank name/number
Tank capacity
Location(s)
Event
Date
(for Management event include Start pt. / End pt.)
Volume
Discharge to US waters
Select event
Select event
Select event
Select event
Select reason
If BW management was *not* conducted for this tank, select one of the following reasons
Ballast Water History
Tank name/number
Tank capacity
Location(s)
Event
Date
(for Management event include Start pt. / End pt.)
Volume
Discharge to US waters
Select event
Select event
Select event
Select event
Select reason
If BW management was *not* conducted for this tank, select one of the following reasons
Tank name/number
Tank capacity
Location(s)
Event
Date
(for Management event include Start pt. / End pt.)
Volume
Discharge to US waters
Select event
Select event
Select event
Select event
Select reason
If BW management was *not* conducted for this tank, select one of the following reasons
Tank name/number
Tank capacity
Location(s)
Event
Date
(for Management event include Start pt. / End pt.)
Volume
Discharge to US waters
Select event
Select event
Select event
Select event
Select reason
If BW management was *not* conducted for this tank, select one of the following reasons
Tank name/number
Tank capacity
Location(s)
Event
Date
(for Management event include Start pt. / End pt.)
Volume
Discharge to US waters
Select event
Select event
Select event
Select event
Select reason
If BW management was *not* conducted for this tank, select one of the following reasons
Ballast Water History
Tank name/number
Tank capacity
Location(s)
Event
Date
(for Management event include Start pt. / End pt.)
Volume
Discharge to US waters
Select event
Select event
Select event
Select event
Select reason
If BW management was *not* conducted for this tank, select one of the following reasons
Tank name/number
Tank capacity
Location(s)
Event
Date
(for Management event include Start pt. / End pt.)
Volume
Discharge to US waters
Select event
Select event
Select event
Select event
Select reason
If BW management was *not* conducted for this tank, select one of the following reasons
Tank name/number
Tank capacity
Location(s)
Event
Date
(for Management event include Start pt. / End pt.)
Volume
Discharge to US waters
Select event
Select event
Select event
Select event
Select reason
If BW management was *not* conducted for this tank, select one of the following reasons
Tank name/number
Tank capacity
Location(s)
Event
Date
(for Management event include Start pt. / End pt.)
Volume
Discharge to US waters
Select event
Select event
Select event
Select event
Select reason
If BW management was *not* conducted for this tank, select one of the following reasons
Ballast Water History
Tank name/number
Tank capacity
Location(s)
Event
Date
(for Management event include Start pt. / End pt.)
Volume
Discharge to US waters
Select event
Select event
Select event
Select event
Select reason
If BW management was *not* conducted for this tank, select one of the following reasons
Tank name/number
Tank capacity
Location(s)
Event
Date
(for Management event include Start pt. / End pt.)
Volume
Discharge to US waters
Select event
Select event
Select event
Select event
Select reason
If BW management was *not* conducted for this tank, select one of the following reasons
Tank name/number
Tank capacity
Location(s)
Event
Date
(for Management event include Start pt. / End pt.)
Volume
Discharge to US waters
Select event
Select event
Select event
Select event
Select reason
If BW management was *not* conducted for this tank, select one of the following reasons
Tank name/number
Tank capacity
Location(s)
Event
Date
(for Management event include Start pt. / End pt.)
Volume
Discharge to US waters
Select event
Select event
Select event
Select event
Select reason
If BW management was *not* conducted for this tank, select one of the following reasons

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