Annex IV - Appendix - Form of International Sewage Pollution Prevention Certificate

Issued under the provisions of the International Convention for the Prevention of Pollution from Ships, 1973, as modified by the Protocol of 1978 relating thereto, as amended, (hereinafter referred to as "the Convention") under the authority of the Government of:

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

(full designation of the country)

by. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

(full designation of the competent person or organization
authorized under the provisions of the Convention)

Particulars of ship¹

Name of ship . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Distinctive number or letters . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Port of registry . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Gross tonnage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Number of persons which the ship is certified to carry . . . . . . . . . . . . . . . . . . . .

IMO Number². . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

New/existing ship^*

Date on which keel was laid or ship was at a similar stage of construction or, where applicable, date on which work for a conversion or an alteration or modification of a major character was commenced. . . . . . . . . . . . . . . . . . .

THIS IS TO CERTIFY:

1 That the ship is equipped with a sewage treatment plant/comminuter/ holding tank* and a discharge pipeline in compliance with regulations 9 and 10 of Annex IV of the Convention as follows:

*	1.1	Description of the sewage treatment plant: Type of sewage treatment plant . . . . . . . . . . . . . . . . . . . . . . . Name of manufacturer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . The sewage treatment plant is certified by the Administration to meet the effluent standards as provided for in resolution MEPC.2(VI).
*	1.2	Description of comminuter: Type of comminuter . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Name of manufacturer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Standard of sewage after disinfection . . . . . . . . . . . . . . . . . . . . .
*	1.3	Description of holding tank: Total capacity of the holding tank . . . . . . . . . . . . . . . . . . . m³ Location . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
	1.4	A pipeline for the discharge of sewage to a reception facility, fitted with a standard shore connection.

2 That the ship has been surveyed in accordance with regulation 4 of Annex IV of the Convention.

3 That the survey shows that the structure, equipment, systems, fittings, arrangements and material of the ship and the condition thereof are in all respects satisfactory and that the ship complies with the applicable requirements of Annex IV of the Convention.

This Certificate is valid until . . . . . . . . . . . . . . . . . . . . . .³ subject to surveys in accordance with regulation 4 of Annex IV of the Convention.

Completion date of survey on which this Certificate
is based: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .(dd/mm/yyyy)

Issued at. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

(place of issue of Certificate)

(dd/mm/yyyy) . . . . .		. . . . . . . . . . . . . . . . . . . . . . . . . . .
(date of issue)		(signature of authorized official issuing the Certificate)

(Seal or stamp of the authority, as appropriate)

Endorsement to extend the Certificate if valid for less
than 5 years where regulation 8.3 applies

The ship complies with the relevant provisions of the Convention, and this Certificate shall, in accordance with regulation 8.3 of Annex IV of the Convention, be accepted as valid until (dd/mm/yyyy): . . . . . . . . . . . . . . . .

	Signed: . . . . . . . . . . . . . . . . . . . . . . . . . .
	(signature of authorized official)
	Place: . . . . . . . . . . . . . . . . . . . . . . . . . . .
	Date (dd/mm/yyyy):. . . . . . . . . . . . . . . .

(Seal or stamp of the authority, as appropriate)

Endorsement where the renewal survey has been completed
and regulation 8.4 applies

The ship complies with the relevant provisions of the Convention, and this Certificate shall, in accordance with regulation 8.4 of Annex IV of the Convention, be accepted as valid until (dd/mm/yyyy): . . . . . . . . . . . . . . . .

	Signed: . . . . . . . . . . . . . . . . . . . . . . . . . .
	(signature of authorized official)
	Place: . . . . . . . . . . . . . . . . . . . . . . . . . . .
	Date (dd/mm/yyyy):. . . . . . . . . . . . . . . .

(Seal or stamp of the authority, as appropriate)

Endorsement to extend the validity of the Certificate
until reaching the port of survey or for a period of grace
where regulation 8.5 or 8.6 applies

This Certificate shall, in accordance with regulation 8.5 or 8.6 * of Annex IV of the Convention, be accepted as valid until (dd/mm/yyyy): . . . . . . . . . . . . .

	Signed: . . . . . . . . . . . . . . . . . . . . . . . . . .
	(signature of authorized official)
	Place: . . . . . . . . . . . . . . . . . . . . . . . . . . .
	Date:. . . . . . . . . . . . . . . . . . . . . . .

(Seal or stamp of the authority, as appropriate)

* Delete as appropriate.
¹ Alternatively, the particulars of the ship may be placed horizontally in boxes.
² Refer to the IMO Ship Identification Number Scheme adopted by the Organization by resolution A.600(15).
³ Insert the date of expiry as specified by the Administration in accordance with regulation 8.1 of Annex IV of the Convention. The day and the month of this date correspond to the anniversary date as defined in regulation 1.8 of Annex IV of the Convention.