Western Port Ballast Water Reporting Form

Ships particulars for vessel discharging ballast water in Western Port

1) Vessel Name: 7) ETA Western Port: 07:18
2) Voyage Number: 8) Berth at Western Port:
3) IMO/Lloyd's Number: 9) Net Tonnage:
4) Radio Call Sign: 10) Number of Cargo Holds/Tanks/Decks:
5) Last Port of Call: 11) Vessel Type:
6) ETD Last Port of Call: 12) Country of Registry:

13) Have you previously provided the Harbour Master, Western Port with an AQIS Strainer Details Form?
YES NO(fill out a Strainer Details Form and submit to the Harbour Master, Western Port with this report)

14) Are you operating in accordance with an EPA or AQIS compliance agreement for the current voyage to Western Port?
YES (If YES, sign at 21 and submit) NO

15) Did you exchange ballast at sea independent of the AQIS DSS Report?
YES (If YES, sign at 21 and submit) NO

16) Have you used the AQIS DSS to perform a risk assessment on the ballast water to be discharged into Western Port
waters?
YES NO (If NO, contact the Harbour Master, Western Port immediately)

17) If YES, what is the Risk Assessment Number (RAN) assigned to your vessel by the AQIS DSS?

RAN:

18) If your AQIS DSS result was HIGH will you have completed an approved ballast water treatment/exchange at sea before
arrival in Western Port?
YES NO (go to Q 20.)

19) If YES indicate below what approved ballast water treatment/exchange method you used.

YESSequential [Empty/refill] YESFlow Through YESDilution Method YESOther

If other please specify:

20) If approved treatment was not conducted fully in any of the tanks/holds intended for discharge at Western Port, please
state the reason and contact the Harbour Master, Western Port immediately:

21) Declared by (Printed Name): Signature: Rank:

Shipping Agency Name: Shipping Agency Phone No:

Shipping Agency Fax No: Date:

Fax form to the Harbour Master, Western Port. Fax No: +613 5983 8684. For further assistance call +613 5983 9406.
Please make completed ballast water uptake/discharge logs and ballast water treatment/exchange logs available to
the Harbour Master, Western Port.