Ship's Particulars:

Ship's name: Crew: Collectors: ANMOBO (Antwerp Motor Boats)

IMO-number: Passengers: BOS (Belgian Oil Services)
Date: / / Duration last trip: h BRABO (Brabo)
Ship's Stay Number: (for agent) KAYAK (Kayak)
Incinerator Capacity: L/H MARPOL (Marpobel)
On Board Vacuum System: YES / NO / UNKNOWN

MARPOL Type Specification To be delivered in Max. Dedicated Amount of waste Last port of delivery Date at which Port at which Est. Amount of Collector
CAT. Antwerp (m³) storage capacity retained on board of this type of waste waste was remaining waste waste generated (Only if waste is
(m³) in Antwerp (m³) delivered in the will be delivered between being delivered
"last port of notification and in Antwerp)
delivery" next port of call
I Cargo Residues N/A N/A N/A N/A N/A N/A N/A N/A N/A

Oil Bilges (*)

Sludge (*)

Dirty Ballastwaters N/A N/A N/A N/A N/A N/A N/A N/A N/A

Other (to be specified) N/A N/A N/A N/A N/A N/A N/A N/A N/A

II Cargo Residues (to be N/A N/A N/A N/A N/A N/A N/A N/A N/A
specified)

Chemicals Washing Waters N/A N/A N/A N/A N/A N/A N/A N/A N/A

Other (to be specified) N/A N/A N/A N/A N/A N/A N/A N/A N/A

IV Black Water N/A N/A N/A N/A N/A N/A N/A N/A N/A

Sewage Grey Water N/A N/A N/A N/A N/A N/A N/A N/A N/A

V Cargo Associated N/A N/A N/A N/A N/A N/A N/A N/A N/A
Waste
Garbage Food Waste (*)

Plastic (*)

Dry-cargo Residues (to N/A N/A N/A N/A N/A N/A N/A N/A N/A
be specified)

Small Dangerous N/A N/A N/A N/A N/A N/A N/A N/A N/A
Waste
Other (*)
(to be specified)