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OMB Approval No. 1625-0066

U.S. Department of Homeland Security U.S. Coast Guard CG-6083 (12-07)
Vessel Response Plan Review Team Commandant, USCG (CG-5431) 2100 Second St. S.W Rm. 2100 Washington, DC 20593 Fax: (202) 372-1921 1. PLAN HOLDER (Company and POC)

SUBMISSION DATE

APPLICATION FOR APPROVAL/REVISION OF VESSEL POLLUTION RESPONSE PLANS
1a. ADDRESS

VRP CONTROL NUMBER

VESSEL NAME

1b. TELEPHONE 1c. FAX 1d. E-MAIL

2. PLAN PREPARER

2a. ADDRESS

2b. TELEPHONE 2c. FAX 2d. E-MAIL

3. PLAN TYPE (Check all that apply): Vessel Response Plan for Oil (Subpart D) Primary Carrier Manned Unmanned Secondary Carrier Tanker Loading Cargo at a Facility Permitted under the Trans-Alaska Pipeline Authorization Act (Subpart E) Vessel Carrying Animal Fats and Vegetable Oils as Primary Cargo (Sub F) Vessel Carrying other Non-Petroleum Oils as a Primary Cargo (Subpart G) Nontank Vessel Response Plan (NTVRP) Shipboard Oil Pollution Emergency Plan (SOPEP) Shipboard Marine Pollution Emergency Plan for Noxious Liquid Substances (SMPEP) 6. OTHER EXPLAINED

4. SUBMISSION TYPE (Check all that apply): Original or New Plan Submission Revision (Revision Number:________) Add/Delete COTP Zone Change in Owner/Operator
(33CFR155.1070(c)(1))

5. ACTION (Check all that apply): Approval (Applies to new, resubmitted, or reactivated plans and revisions that affect the plan holder, added vessels, zone changes, and vessel name changes.) Duplicate Approval Letter Corrected Approval Letter Plan Deactivation Plan Reactivation Vessel Deactivation Vessel Reactivation Policy Interpretation Plan Review Status No Response Needed Other (Please explain below)

Vessel Name Change Add/Change Oil Group Carried OSRO Change QI Change Add/Delete Vessel Change or Correction Annual Review Resubmission 5 Year Re-Approval Change in Owner/Operator
(33CFR155.1070(b)(2))

Nontank VRP Recertification (2 Year) Other (Please explain below)

OFFICE USE ONLY

7. ATTACHMENTS INCLUDED1: Entire Plan Revision Filing Instructions Revision(s) Vessel Specific Appendix Geographic Specific Appendix Plan Holder Information Changed/Corrected Pages Record of Changes List of Effected Pages

8. VESSEL RESPONSE PLAN CERTIFICATION AND AUTHORIZATION: (ensure signature and name is legible) I, (print name)__________________________________________________, certify that this submission meets all applicable requirements set forth in (circle applicable subparts) 33CFR155 / subpart D / subpart E / subpart F / subpart G / and/or 33 U.S.C. 1321(j) (5), and that I have identified and ensured the availability of, through contract or other approved means, the necessary private resources to respond to the maximum extent practical, a worst case discharge or a substantial threat of such a discharge from the vessel. (See 18 U.S.C. 1001) Authorizing Signature: _________________________________________________________________ 9. SOPEP/SMPEP AUTHORIZATION: (ensure signature and name is legible) Authorizing Signature:__________________________________________________________________ Date:____________________ Date:____________________

NOTE: 1. This application and attachments may be faxed to (202) 372-1921 or emailed to [email protected] providing that faxes are less than 15 pages and electronic documents are less than 15 pages and less than 1.5 megabytes. An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a valid OMB control number. The Coast Guard estimates that the average burden for this report is 10 minutes. You may submit any comments concerning the accuracy of this burden or any suggestions for reducing the burden to: Commandant (CG-5431), U.S. Coast Guard Paperwork Reduction Project (1625-0066), Washington, DC 20593-0001.

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Page 2 of CG-6083 (Rev. 12-07)

10. COMMENTS

INTRODUCTION: This application is offered as an optional replacement or supplement to submitting a cover letter. This application is intended to: simplify the plan submission process for industry, simplify the review process for Coast Guard personnel, and promote a standardized procedure in an attempt to reduce the amount of time required for the review process. When submitted properly, this application meets the requirement for a Vessel Response Plan certification statement as required by 33 CFR 155.1065(b). This application may be submitted with the plan(s) or revision(s) to the Vessel Response Plan Program (CG-5431) Room 2100, 2100 Second St. S.W. Washington, D.C 20593-0001. To ensure Coast Guard receipt of your plan or revisions it is recommended that items be sent via trackable means such as a courier service or the Postal Service's Registered Mail system. This application may be submitted by facsimile to 202372-1921 and electronic mail only if the total submission is no greater than 15 pages per week and less than 1.5 megabytes. If this application is faxed or emailed to [email protected] and is intended to act as a valid certification statement, please ensure that a legible signature is provided. INSTRUCTIONS BLOCK 1: Enter the Plan Holder information. Include company name and point of contact. BLOCK 1a.: Enter the address for the Plan Holder. Include: street, city, state/province, and zip/postal code. BLOCK 1b.: Enter the telephone number for the Plan Holder point of contact. Include country and area code as applicable. BLOCK 1c.: Enter the fax number for the Plan Holder point of contact. Include country and area code as applicable. BLOCK 1d.: Enter a valid email address for the Plan Holder point of contact if available. BLOCK 2: Enter the Plan Preparer information. Include company name and point of contact or plan writer. If the subject plan is prepared by the Plan Holder, select the "Same as block 1" option BLOCK 2a.: Enter the address for the Plan Preparer. Include: street, city, state/province, and zip/postal code. BLOCK 2b.: Enter the telephone number for the Plan Preparer. Include country and area code as applicable. BLOCK 2c.: Enter the fax number for the Plan Preparer. Include country and area code as applicable. BLOCK 2d.: Enter a valid email address for the Plan Preparer if available. BLOCK 3: Select the type(s) of plan(s) to be submitted with this application. BLOCK 4: Select the type(s) of submission(s) enclosed with this application. BLOCK 5: Select the action or response requested. Note: Approval letters will only be issued for plans that are new, resubmitted, or reactivated, and for revisions that request a change in plan holder, added vessels, vessel name changes, and COTP zone changes. BLOCK 6: Explain in detail any submission that is not covered above. BLOCK 7: Select the type(s) of attachments included with this application. BLOCK 8: For Vessel Response Plans: The vessel owner or operator (as defined in 33 CFR 155.1020) should read and sign the certification to indicate the submitted plan meets the requirements of 33 CFR 155 subpart D, E, F, or G (as applicable) for the vessel(s) listed. Certification indicates the vessel owner or operator accepts responsibility for the compliance of the vessel(s) in the event of an incident or marine casualty. Certification statements must be submitted in accordance with 33 CFR 155.1065(b) and 33 CFR 155.1070(d). BLOCK 9: For Shipboard Oil Pollution Emergency Plans/Shipboard Marine Pollution Emergency Plans: This block should be completed by a person authorized to write and revise the submitted plan. BLOCK 10: Space for additional comments and suggestions.
U.S. Dept. of Homeland Security, USCG, CG-6083 (Rev. 12-07)

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