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FORM QAC-020-01-00

To: NIPPON KAIJI KYOKAI / Date:
APPLICATION
for Verification of Vessels under Clean Shipping Index (CSI)
I, the undersigned applicant, request NIPPON KAIJI KYOKAI, to provide the verification service as described below in accordance with the “Rules for Verification of Ships and Shipping Companies on Environmental Performance”.
Organization
Name:
Address :
Representative:
Name / Position
Person in Charge:
Name / Position
Tel. / Fax.
E-Mail
(Please fill in an appropriate organization or departmental e-mail address.)
Number of Vessels
owned/time-chartered
Vessels to verify / Vessel Name / IMO No. / Vessel Type
1)
2)
3)
4)
5)
6)
7)
8)
ExpectedDates
for Verification / (For Company)
(For Vessels)
(*If the schedule is not fixed, please inform us later)
Applicant
&
Billing
address / □: as stated below / □: as stated above
- Organization
- Tel. No. / Fax. No.
- Name & Position
- Signature

(To be continued)

Note: Please use the latest version downloaded from ClassNKwebsite(),

then fill out completely and file with ClassNK.

2013.11.01

FORM QAC-020-01-00 Attachment

To: NIPPON KAIJI KYOKAI / Date:
Documents required for vessel verification
□Bunkering documents, SOx
□Type and mass of fuel consumed within ECA-Sox –preferably over one calendar year, SOx
□Oil record book, SOx
□IAPP certificate, SOx
□EIAPP certificates for all engines, if applicable, NOx
□Other approved NOx measurements, if applicable, NOx
□Overview of each voyage, split on ballast and laden legs if applicable, with sailed distance, port calls, cargo transported, type and mass of fuel consumed for main engine, auxiliary engines, boilers and other consumption.
Data preferably available over one calendar year, CO2
□Documentation explaining methodology and calculation used for establishing CO2 footprint, CO2
□TDS (Technical Data Sheet), Antifouling
□AFS certificate, Antifouling
□MSDS (Materials Safety Data Sheet), Antifouling
□TDS (Technical Data Sheet), Stern tube oil
□MSDS (Materials Safety Data Sheet), Stern tube oil
□TDS (Technical Data Sheet), External hydraulic fluids
□MSDS (Materials Safety Data Sheet),External hydraulic fluids
□TDS (Technical Data Sheet), Gear oils for thrusters and controllable pitch (CP) propellers
□MSDS (Materials Safety Data Sheet),Gear oils for thrusters and controllable pitch (CP) propellers
□TDS (Technical Data Sheet), Boiler/Cooling water treatment
□MSDS (Materials Safety Data Sheet),Boiler/Cooling water treatment
□TDS (Technical Data Sheet), Cleaning agents
□MSDS (Materials Safety Data Sheet),Cleaning agents
□MSDS (Materials Safety Data Sheet), Refrigerants
□TDS (Technical Data Sheet), Refrigerants
□Refrigerant Record Book, Refrigerants
□Ballast Water Record Book, Ballast water treatment
□Ballast water operating manual, Ballast water treatment
□Certificate of Type approval of ballast water treatment systems, if applicable, Ballast water treatment
□Certificate of Type Approval for Sewage Treatment Plant, if applicable, Sewage
□ISPP certificate, if in place, Sewage
□PMS documentation of tests, if in place, Sewage
□Sewage handling manuals, Sewage
□Garbage Record Book, Garbage handling
□Garbage Management Plan, Garbage handling
□IOPP Certificate, Sludge handling
□Oil record book documentation, Sludge handling
□IOPP Certificate, Bilge water treatment
□PMS documentation of tests, if in place, Bilge water treatment
Remarks

Note: Please use the latest version downloaded from ClassNKwebsite(),

then fill out completely and file with ClassNK.

2013.11.01