SCHEDULE OF VESSEL INFORMATION Washington State Maritime Cooperative (WSMC) Enrollment Agreement and...

SCHEDULE OF VESSEL INFORMATION Washington State Maritime Cooperative (WSMC) Enrollment Agreement and Emergency Response Towing Vessel (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) *

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: *

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: *

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: