ANNEX 3附則
ANNEX 3 STANDARD FORMAT FOR THE WASTE DELIVERY RECEIPT The designated representative of the port reception facility provider shall provide the following form to the master of a ship that has delivered waste in accordance with Article 7 of Directive (EU) 2019/883 This form shall be retained on board the ship along with the appropriate Oil Record Book, Cargo Record Book, Garbage Record Book or Garbage Management Plan as required by the MARPOL Convention. Text of image 1. PORT RECEPTION FACILITY AND PORT PARTICULARS 1.1. Location/terminal name: 1.2. Port reception facility provider(s): 1.3. Treatment facility provider(s) – if different from above: 1.4. Waste delivery date and time from: to: 2. SHIP PARTICULARS 2.1. Name of the ship: 2.5. Owner or operator: 2.2. IMO number: 2.6. Distinctive number or letters: MMSI (Maritime Mobile Service Identity) number: 2.3. Gross tonnage: 2.7. Flag State: 2.4. Type of ship: Oil tanker Chemical tanker Bulk carrier Container Other cargo ship Passenger ship Ro-ro Other (specify) Text of image 3. TYPE AND AMOUNT OF WASTE RECEIVED MARPOL Annex I – Oil Quantity (m 3 ) MARPOL Annex V – Garbage Quantity (m 3 ) Oily bilge water A. Plastics Oily residues (sludge) B. Food waste Oily tank washings C. Domestic waste (e.g. paper products, rags, glass, metal, bottles, crockery, etc.) Dirty ballast water D. Cooking oil Scale and sludge from tank cleaning E. Incinerator ashes Other (please specify) F. Operational waste MARPOL Annex II – NOXIOUS LIQUID SUBSTANCES (NLS) Quantity (m 3 )/Name ( 1 ) G. Animal carcass(es) Category X substance H. Fishing gear Category Y substance I. E-waste J. Cargo residues ( 2 ) (Harmful to the Marine Environment – HME) K. Cargo residues ( 2 ) (non-HME) MARPOL Annex VI – Air Pollution related Quantity (m 3 ) Category Z substance Ozone-depleting substances and equipment containing such substances OS – other substance Exhaust gas-cleaning residues MARPOL Annex IV – Sewage Quantity (m 3 ) Other waste, not covered by MARPOL Quantity (m 3 ) Passively fished waste ( 1 ) Indicate the proper shipping name of the NLS involved. ( 2 ) Indicate the proper shipping name of the dry cargo. ( 1 ) ( 2 ) ( 2 )