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INSTRUCTIONS

The Certificate of Adequacy (COA) Application FORM B
The following instructions for individual line items are provided to assist in completing the Application for a Certificate of Adequacy (COA). If you have any questions or need assistance in completing the Application, please contact the U.S. Coast Guard Captain of the Port (COTP) for your area. A list of definitions, which you may find helpful in completing the Application, is provided in 33 Code of Federal Regulations Part 158 (33 CFR 158). 1.A. Indicate terminal if you are applying as a single terminal or indicate port if you are applying as a group of terminals. Do not mark "COTP Designated Port" unless you have a letter from the COTP with such a designation. COTP designation of a facility or an area as a port is for unusual situations. If you have a question as to whether COTP designation as a port applies to your situation, contact the COTP for your area. 1.C. (1) For a terminal, enter the company or corporation name. For a port, enter the company, corporation, port authority, or organization by which the group of terminals is legally known. 1.C.(3) Enter the name of a person authorized to act in behalf of the terminal or port. 1.C.(5) For a terminal, enter the company or corporation name. For a port, enter the company, corporation, port authority, or organization of which the person in charge is a member. 1.D.(1) Those applying as terminals do not have to complete this section, since the information is the same as in 1.C. Ports are to provide this information for each of the terminals indicated in 1.B. 2.A.(1) Enter the company or corporation name of the reception facility. 2.A.(5) Check as many of the types of reception facilities as may be used. 3.A. Enter the capacity of the Reception Facility to handle the specified wastes. 3.H. Only ship repair yards need complete this line item. The Coast Guard estimates that the average burden for this report form is 45 minutes. You may submit any comments concerning the accuracy of this burden estimate or any suggestions for reducing the burden to: Commandant (G-MEP-1), U.S. Coast Guard, Washington, DC 20593-0001 or Office of Management and Budget, Office of Information and Regulatory Affairs, Attn.: Desk Officer for DOT/USCG, Old Executive Building, Washington, DC 20503.

U.S. DEPT. OF HOMELAND SECURITY, USCG, CG-5401B (Rev. 6-04)

OMB No. Approved: 1625-0045 Burden hours: 3 hours for new facilities U.S. DEPARTMENT OF HOMELAND SECURITY U.S. COAST GUARD CG-5401B (Rev. 6-04)

Application For a Reception Facility Certificate of Adequacy For Noxious Liquid Substance (NLS) Residues and Mixtures Containing NLS Residues

1. PARTICULARS OF TERMINAL OR PORT A. APPLYING AS: (Check one) Terminal Port COTP Designated Port Ship Repair Yard B. NUMBER OF TERMINALS TO WHICH THIS APPLICATION APPLIES: C. TERMINAL/PORT INFORMATION: (1) Name of Terminal/Port (2) Address of Terminal/Port

(3) Name of Terminal/Port Person-in-Charge (4) Title/Position (5) Organization (6) Office Phone Number ( ) D. INDIVIDUAL TERMINAL INFORMATION: If applying as a port, list the information indicated for each terminal in the port. If more space is needed, continue on a separate sheet of paper and attach to the back of the application. The signature of the person in charge of the terminal acknowledges that the terminal agrees and volunteers to being considered as a member of the port, described in section 1, for purposes of these reception facilities. Complete the terminal name, location, etc. below. (1) Name of Terminal (a) Address of Terminal

(b) Name/Title Person-in-Charge (c) Office Phone Number (d) Signature of Terminal Person-in-Charge (2) Name of Terminal (a) Address of Terminal ( )

(b) Name/Title Person-in-Charge (c) Office Phone Number (d) Signature of Terminal Person-in-Charge 2. PARTICULARS OF RECEPTION FACILITY: Enter information for each reception facility used by the terminal/port. If necessary, continue on a separate sheet and attach to the back of the application. A. NAME OF RECEPTION FACILITY B. ADDRESS ( )

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Page 2. of CG-5401B (Rev. 6-04)

C. NAME AND TITLE OF PERSON IN CHARGE D. OFFICE PHONE NUMBER OF PERSON IN CHARGE ( E. TYPE OF RECEPTION FACILITY: (Check those that apply) Fixed (Describe other) 3. TYPE OF NLS CARGO OR RESIDUES UNLOADED AT THE TERMINAL OR PORT DURING THE LAST 12 MONTHS: ( Check the boxes that apply. If 3.A., 3.B., or 3.C. is checked, indicate the specific NLS handled on an attached sheet or check the appropriate cargoes on the attached COTP optional NLS cargo list: A. Category A B. Category B solidifying or high viscosity C. Category C solidifying or high viscosity D. Category B non-solidifying or non-high viscosity E. Category C non-solidifying or non-high viscosity F. Category D 4. TERMINAL AND PORT REQUIREMENTS: (Only complete this section if the items 3.B., 3. C., 3.D., or 3.E. are checked.) A. WILL THE PORT OR TERMINAL BE CAPABLE OF RECEIVING NLS CARGO DURING TANK STRIPPING OPERATIONS FROM SHIPS AT AN INSTANTANEOUS FLOW RATE OF 6 CUBIC METERS (158.4 Gallons) PER HOUR WITHOUT THE BACK PRESSURE EXCEEDING 101.6 kPa/sec (14.7 pounds per square inch gauge) AT THE POINT WHERE THE SHORE CONNECTION MEETS THE SHIPS MANIFOLD? Yes No B. WILL THE INSTRUCTION MANUAL THAT LISTS THE EQUIPMENT AND PROCEDURES REQUIRED BY LINE ITEM 4.A. BE AVAILABLE AT THE TERMINAL PORT? Yes No Mobile Tank Truck Tank Other )

5. RECEPTION FACILITY REQUIREMENTS: (Only complete this section if line items 3.A., 3. B., or 3.C. are checked. For line items 5.A. and 5.B. enter either the capacity or "N/A." for the items 5.C. through 5.G. enter either "YES," "NO," or "N/A". If entering "NO" explain on a separate attached sheet). A. ESTIMATED DAILY CAPACITY OF RECEPTION FACILITY TO RECEIVE NLS RESIDUES RESULTING FROM PREWASH OPERATIONS: (Cubic Meters) B. ESTIMATED DAILY CAPACITY REQUIREMENT OF THE TERMINAL/PORT TO RECEIVE NLS RESIDUES RESULTING FROM PREWASH OPERATIONS: (Cubic Meters) C. CAN THE RECEPTION FACILITY RECEIVE ALL NLS RESIDUES RESULTING FROM PREWASH OPERATIONS FROM SHIPS WITHIN 10 HOURS AFTER NLS Yes No N/A RESIDUE TRANSFER BEGINS? D. WILL THE RECEPTION FACILITIES FOR NLS RESIDUES BE PROVIDED WITHIN 24 HOURS AFTER NOTIFICATION BY A VESSEL INDICATING THE NEED FOR No Yes N/A RECEPTION FACILITIES? E. WILL THE RECEPTION FACILITIES BE PROVIDED AT THE UNLOADING TERMINAL/PORT? F. DOES THE RECEPTION FACILITY HOLD EACH FEDERAL, STATE, AND LOCAL PERMIT AND LICENSE REQUIRED BY ENVIRONMENTAL LAWS AND REGULATIONS CONCERNING NLS RESIDUES? G. CAN THE RECEPTION FACILITY RECEIVE ALL NLS RESIDUES PRIOR TO THE SHIP LEAVING THE SHIP REPAIR YARD? Yes No N/A

Yes Yes

No No

N/A N/A

CERTIFICATION I hereby certify that the information provided in this application for a waste reception facility certificate of adequacy for reception facilities receiving noxious liquid substance (NLS) residues is complete, true and correct to the best of my knowledge, information, and belief.
Signature of Terminal/Port Person-in-Charge Printed or Typed Name of Person-in Charge Date Signed

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