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OMB No. Approved 1625-0045 Burden hours: .75 per response U.S. DEPARTMENT OF HOMELAND SECURITY U.S. COAST GUARD CG-5401C (6-04)

Application for a Reception Facility Certificate of Adequacy for Garbage FORM C

The Act to Prevent Pollution From Ships (33 USC 1901) authorizes the Department of Homeland Security to issue certificates to Terminals and Ports verifying their adequacy to receive operational garbage from ships. Regulations implementing this program are in 33 CFR Code of Federal Regulations Part 158. To continue to receive ships at a port or terminal an applicant must hold a Certificate of Adequacy for Garbage if it receives oceangoing tankers, or any other oceangoing ship of 400 gross tons or more, carrying residues and mixtures containing oil; or if it receives oceangoing ships carrying Noxious Liquid substances. To receive a Certificate of Adequacy for Garbage, application is required on FORM C.

Definitions: "Terminal": an onshore facility or an offshore structure located in the navigable waters of the United States or subject to the jurisdiction of the United States and used, or intended to be used, as a fac ility for the transfer or other handling of a harmful substance. The definition of "navigable waters" for the purposes of this section may be found in 33 CFR 2.05-25. (1) a group of terminals that combines to act as a unit and be considered a port for purposes of this part; (2) a port authority or other organization that chooses to be considered a port for purposes of this part. For the purposes of Annex V of MARPOL 73/78, Port also means a commercial fishing facility, recreational boating facility and a mineral and oil industry shorebase. 2. Check the following boxes if the terminal receives or discharges any of the following cargoes from vessels visiting the terminal: Oil Oily wastes Fuel Bulk dry cargo Explosives Hazardous Substances Fish Other Discharge Discharge Discharge Discharge Discharge Discharge Discharge Discharge Receive Receive Receive Receive Receive Receive Receive Receive

"Port":

A. Terminal Section:
1. Complete this section if you are applying as a SINGLE TERMINAL. Name of Terminal

Street Address

City

State

Zip Code

3. Check the following boxes if the terminal handles or services any of the following vessels: Vessels of Foreign registry U.S. Vessels on domestic trade U.S. Vessels in foreign trade Passenger vessels Vessels servicing the offshore Mineral and Oil industry Unmanned Barges Chemical ships Container ships Break bulk ships Ferry boat ships Fishing ships

Name of Terminal Person-in-Charge

Phone Number (Enter Area Code) After completing this section go to Section C.

B. Port Section:
1. Complete this section if you are applying as a PORT. Name of Terminal

Street Address

City

State

Zip Code

Name of Terminal Person-in-Charge

Number of Terminals which will be members of this Port?:

Phone Number (Enter Area Code)

The Coast Guard estimates that the average burden hours 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 DHS/USCG, Old Executive Office Building, Washington, DC 20503.

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Page 2. of CG-5401C (6-04)

B. Port Section (continued) Individual terminal data:
Ports are to complete the following entries for each individual terminal which is a member of the port. 2. 5. Check the following boxes if the terminal receives or discharges any of the following cargoes from vessels visiting the terminal: Name of Terminal Oil Oily wastes Fuel Bulk dry cargo Explosives Hazardous Substances Fish Other Discharge Discharge Discharge Discharge Discharge Discharge Discharge Discharge Receive Receive Receive Receive Receive Receive Receive Receive

Street Address

City

State

Zip Code

Name of Terminal Person-in-Charge

6. Check the following boxes if the terminal handles or services any of the following vessels: Vessels of Foreign registry U.S. Vessels on domestic trade U.S. Vessels in foreign trade Passenger vessels Vessels servicing the offshore Mineral and Oil industry Unmanned Barges Chemical ships Container ships Break bulk ships Ferry boat ships Fishing ships

Phone Number (Enter Area Code)

Signature of Person-in-Charge of Terminal (Signature indicates Terminal Acknowledges that terminal agrees and consents to being considered as a member of the port, described in Section B.) 3.

7. Check the following boxes if the terminal receives or discharges any of the following cargoes from vessels visiting the terminal: Oil Oily wastes Fuel Bulk dry cargo Explosives Hazardous Substances Fish Other Discharge Discharge Discharge Discharge Discharge Discharge Discharge Discharge Receive Receive Receive Receive Receive Receive Receive Receive

Name of Terminal

Street Address

City

State

Zip Code

Name of Terminal Person-in-Charge

8. Check the following boxes if the terminal handles or services any of the following vessels: Vessels of Foreign registry U.S. Vessels on domestic trade U.S. Vessels in foreign trade Passenger vessels Vessels servicing the offshore Mineral and Oil industry Unmanned Barges Chemical ships Container ships Break bulk ships Ferry boat ships Fishing ships

Phone Number (Enter Area Code)

Signature of Person-in-Charge of Terminal (Signature indicates Terminal Acknowledges that terminal agrees and consents to being considered as a member of the port, described in Section B.) 4.

9. Check the following boxes if the terminal receives or discharges any of the following cargoes from vessels visiting the terminal: Oil Oily wastes Fuel Bulk dry cargo Explosives Hazardous Substances Fish Other Discharge Discharge Discharge Discharge Discharge Discharge Discharge Discharge Receive Receive Receive Receive Receive Receive Receive Receive

Name of Terminal

Street Address

City

State

Zip Code

Name of Terminal Person-in-Charge

10. Check the following boxes if the terminal handles or services any of the following vessels: Vessels of Foreign registry U.S. Vessels on domestic trade U.S. Vessels in foreign trade Passenger vessels Vessels servicing the offshore Mineral and Oil industry -2Unmanned Barges Chemical ships Container ships Break bulk ships Ferry boat ships Fishing ships

Phone Number (Enter Area Code)

Signature of Person-in-Charge of Terminal (Signature indicates Terminal Acknowledges that terminal agrees and consents to being considered as a member of the port, described in Section B.)

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Page 3. of CG-5401C (6-04)

Section C
1. Does the terminal or port receive more than 25 visits from vessels arriving from foreign ports (except Canada), Hawaii or any territories or possessions of the United States? YES NO (If the answer is "NO" go to question No. 3)

2. Does the terminal or port have facilities approved by the Administrator, Animal and Plant Health Inspection Service, U.S. Department of Agriculture, for the disposal of garbage from foreign ports (except Canada), Hawaii or any Territories or Possessions of the United States in accordance with Title 9 Code of Federal Regulations Part 94. YES NO (If the answer is "NO" you may attach a waiver request in accordance with 33 CFR 158 on a separate attached sheet.)

Name of APHIS Approved Facility

Type (Incinerator, Sterilizer, Autoclave, etc.)

City

State

Phone Number

3. For those terminal(s)/port(s) requiring the services of an Animal and Plant Health Inspection Service approved facility, would the terminal or port receive all garbage from these ships visiting the terminal/port within 24 hours of vessel after notification of need for such services is given? YES NO (If the answer is "NO" you may attach a waiver request in accordance with 33 CFR 158 on a separate attached sheet.)

4. Is the terminal or port able to receive all garbage as defined in 33 CFR 158.120 which the master or person-in-charge of a ship desires to discharge, except: (1) large quantities of spoiled or damaged cargoes not normally expected to be discharged by a ship; or (2) garbage from ships not having commercial transactions with that terminal or port? YES NO (If the answer is "NO" you may attach a waiver request in accordance with 33 CFR 158 on a separate attached sheet.)

The terminal/port person-in-charge identified in the Application shall notify the U.S. Coast Guard Captain of the Port (COTP) in writing 30 days after any of the terminal/port information supplied under 33 CFR 158.165(b)(3) changes. Civil Penalties. A person who after notice and an opportunity for a hearing, is found: a. to have made a false, fictitous or fraudulent statement or representation in any matter in which a statement or representation is required to be made under the Act to Prevent Pollution from Ships, or the regulations thereunder, shall be liable to the United States for a civil penalty, not to exceed $5,000 for each statement or representation; or b. to have violated the Act to Prevent Pollution from Ships, or the regulations issued thereunder, shall be liable to the United States for a civil penalty, not to exceed $25,000 for each violation.

CERTIFICATION
I hereby certify that the information provided in this application for a waste reception facility certificate of adequacy for reception facilities receiving garbage 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

Mail the application to: THE LOCAL CAPTAIN OF THE PORT OFFICE -3-

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