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 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) *

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: *

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: