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STANDARD FORMAT OF THE ADVANCE NOTIFICATION FORM FOR WASTE DELIVERY TO PORT RECEPTION FACILITIES Notification of the delivery of waste to: (enter name of port of call, as referred to in Article 6 of Directive (EU) 2019/883) This form should be retained on board the ship along with the appropriate Oil Record Book, Cargo Record Book, Garbage Record Book or Garbage Management Plan as required by the MARPOL Convention.

1. SHIP PARTICULARS 1.1 Name of ship: 1.5 Owner or operator: 1.2 IMO number: 1.6 Distinctive number or letters: MMSI (Maritime Mobile Service Identity) number: 1.3 Gross tonnage: 1.7 Flag State: 1.4 Type of ship: Oil tanker Chemical tanker Bulk carrier Container Other cargo ship Passenger ship Ro-ro Other (specify) 2. PORT AND VOYAGE PARTICULARS 2.1 Location/terminal name: 2.6 Last port where waste was delivered: 2.2 Arrival date and time: 2.7 Date of last delivery: 2.3 Departure date and time: 2.8 Next port of delivery: 2.4 Last port and country: 2.9 Person submitting this form (if other than the master): 2.5 Next port and country (if known): 3. TYPE AND AMOUNT OF WASTE AND STORAGE CAPACITY Type Waste to be delivered (m3) Maximum dedicated storage capacity (m3) Amount of waste retained on board (m3) Port at which remaining waste will be delivered Estimated amount of waste to be generated between notification and next port of call (m3) MARPOL Annex I – Oil Oily bilge water Oily residues (sludge) Oily tank washings Dirty ballast water

Type Waste to be delivered (m3) Maximum dedicated storage capacity (m3) Amount of waste retained on board (m3) Port at which remaining waste will be delivered Estimated amount of waste to be generated between notification and next port of call (m3) Scale and sludge from tank cleaning Other (please specify) MARPOL Annex II – NOXIOUS LIQUID SUBSTANCES (NLS) (1) Category X substance Category Y substance Category Z substance OS – other substances MARPOL Annex IV – Sewage MARPOL Annex V – Garbage A. Plastics B. Food Waste C. Domestic waste (e.g. paper products, rags, glass, metal, bottles, crockery, etc.) D. Cooking Oil E. Incinerator ashes F. Operational waste G. Animal carcass(es) H. Fishing gear I. E-waste (1) Indicate the proper shipping name of the NLS involved. (1)

Type Waste to be delivered (m3) Maximum dedicated storage capacity (m3) Amount of waste retained on board (m3) Port at which remaining waste will be delivered Estimated amount of waste to be generated between notification and next port of call (m3) J. Cargo residues (2) (Harmful to the Marine Environment – HME) K. Cargo residues (3) (non-HME) MARPOL Annex VI – Air Pollution related Ozone depleting substances and equipment containing such substances (4) Exhaust gas cleaning residues Other waste, not covered by MARPOL Passively fished waste Notes 1. This information shall be used for port State control and other inspection purposes.

2. This form is to be completed unless the ship is covered by an exemption in accordance with Article 9 of Directive (EU) 2019/883 (1) May be estimates. Indicate the proper shipping name of the dry cargo.

(2) May be estimates. Indicate the proper shipping name of the dry cargo.

(3) Arising from normal maintenance activities on board.

(2) (3) (4)