SCHEDULE OF VESSEL INFORMATION
Washington State Maritime Cooperative (WSMC) Enrollment Agreement
and
Emergency Response System/Towing Vessel (ERS/ERTV) Enrollment Agreement
ALL VESSEL CHARATERISTICS INFORMATION WILL BE VERIFIED USING LLOYDS
Vessel"s Name:
*
Official or IMO Number:
*
Flag:
*
U.S.?
NON-U.S.?
Gross Registered Tons (GRT):
*
Deadweight Tons (DWT)
*
Build Date:
Will the vessel transit (check all that are applicable):
To/From Washington/US port(s) via the Strait of Juan de Fuca?
YES
To/from Grays Harbor
YES
To/from Washington/US port(s), not using Strait of Juan de Fuca? (NOTE: this would include ferries, fishing vessels & other vessels that travel inside passage, oil barges and other vessels to/from Canada not going west of Race Rocks)
YES
To/from Canadian port(s) only, via the Strait of Juan de Fuca? ( NOTE: this would be the vessels that qualify for the no-fee WSMC Enrollment under the Canada Reciprocal Arrangement Agreement. )
YES
VESSEL TYPE: (CHOOSE IN DROP DOWN MENU)
*
Please Select
Tank Ship (carrying oil of any kind as cargo)
Tank Ship (not carrying oil as cargo)
Tank Barge carrying oil as cargo
Articulate Tug and Barge (carrying oil as cargo)
Gas carrier
Passenger Vessel (not ferry)
Ferry Vessel
Container Ship
Ro/Ro
Car Carrier
Bulk Carrier
Break Bulk Cargo Carrier
Towing Vessel
Fishing Industry Vessel
Other (describe)
Ship Owner/Operator Company:
*
Ship Owner/Operator Mailing Address:
Ship Owner/Operator Telephone No.:
*
Ship Owner/Operator Facsimile No.:
Ship Owner/Operator Email Address:
*
Authorized Agent Company: (if other than Ship Owner/Operator Company)
Name of Authorized Agent:
Authorized Agent Address:
Authorized Agent Telephone No.:
Authorized Agent Facsimile No.:
Authorized Agent E-mail Address
Fuel Oil: Vessel"s Fuel oil Capacity:
*
Type(s) of Fuel Oil Carried:
API Gravity of Fuel Oil Carried
Bulk Oil: Does this vessel carry any bulk oil as cargo?
YES
NO
If YES: API Gravity of Bulk Oil Cargo Carried
If YES: Vessel"s Bulk Oil Cargo Capacity ( BBLS )
If YES: Type of Bulk Oil Cargo
(If more than one type of bulk oil cargo is carried, then list lowest API Gravity)
WORST CASE DISCHARGE (WCD): BBLS
*
(
Oil capacities and Worst Case Discharge quantities are verified through the USCG"s E-VRP website
)
IS THE VESSEL AN MPA/MSRC MEMBER ? ( Vessel may have either MSRC or NRC and enroll with WSMC. However, MPA/MSRC national members that enroll with WSMC may get a credit on their MPA national dues )
YES
NO
Vessel"s P&I Club or Insurer:
*
USCG Vessel Response Plan (VRP) Control number
USCG COFR NO.:
*
USCG COFR Expiration Date:
*
-
Month
-
Day
Year
Date
Qualified Individual provider listed in VRP (Company Name):
*
VRP Oil Spill Removal Organization(s) (OSROs) authorized in the VRP for Seattle (Puget Sound) Zone :
*
QI (Individuals name if applicable):
QI 24/7 Phone Number:
*
Washington State Approved SMT:
ERS/ERTV Information
(
Applicable only to those vessels that call Washington ports via the Strait of Juan de Fuca
)
INFORMATION ON WHICH ERTV FEE CREDITS MAY APPLY:
Fuel tank protection: Does vessel have protectively located fuel tanks per Regulation 12A?
YES
NO
Propulsion: Does vessel have totally independent DUAL PROPULSION?
YES
NO
Safety/Environmental Systems Certification
ISO 14001:
YES
NO
ECOPRO: (applies to tank vessels):
YES
NO
OTHER:
Submit
Should be Empty: