Form concerning reception of operation waste from ships calling the Port of Esbjerg

Following information must be submitted before calls at
the Port of Esbjerg

Name of ship *
Radio call sign *
Name of ship owner/shipmaster/shipping agent/shipbroker
If all waste is delivered, please complete the second column where relevant. If some or no waste is delivered, please complete all columns.

Type

Quantity of
waste to be
delivered

Max. storage
capacity
available

Waste kept
on board

Port at which
remaining
waste will
be delivered

Estimated
quantity of
waste produced
before next
port call

(m3)

1. Waste oil

Slop oil (sludge)

Specification of slop oil

a. Does the material contain
substances other than
oil/waste ?

Yes No

b. If so, please state the
substances

c. Estimated oil
content (%) ?
(accepted min. 65%)

d. Waste to be collected by:

Port of Esbjerg *

Collection Date:

Time:
Other operator *

Bilge water

Other substances(please specify)

2. Garbage

Garbage

Plastic

Other substances

3. Sewage water

Sewage water

4. Cargo-related waste

Cargo-related
waste
(to be specified)

5. Cargo residues

Cargo residues
(to be specified)

Notes: Above information may be used for port control and for other inspection purposes. This form must be completed, unless the ship has been granted exemption pursuant to paragraph 18 of the Executive Order No. 1632 dated December 13, 2006 from Danish Ministry of the Environment concerning ship waste reception facilities, ships delivery of waste and schemes for operating waste from ships in ports. I hereby confirm, - that the information given is accurate and correct, and - that there is sufficient storage facilities on board to store waste produced between the submission of this message and the next port at which the waste will be deposited
Mail address of sender : *