‘ANNEX

INTERNATIONAL CERTIFICATE ON INVENTORY OF HAZARDOUS MATERIALS

(Note: This certificate shall be supplemented by Part I of the inventory of hazardous materials)

(Official seal)

(State)

Issued under the provisions of the Hong Kong International Convention for the Safe and Environmentally Sound Recycling of Ships adopted in Hong Kong on 15 May 2009 (the ‘Hong Kong Convention’) for those Member States that are Parties to the Hong Kong Convention, and under Regulation (EU) No 1257/2013 of the European Parliament and of the Council on ship recycling under the authority of the Government of

…

(Name of State)

by …

(Full designation of the person or organization authorized under the provisions of the Hong Kong Convention and under Regulation (EU) No 1257/2013)

Particulars of the Ship

Name of Ship
Distinctive number or letters
Port of Registry
Gross tonnage
IMO number
Name and address of shipowner
IMO registered owner identification number
IMO company identification number
Date of Construction

Particulars of Part I of the inventory of hazardous materials

Part I of the inventory of hazardous materials identification/verification number: …

Note: Part I of the inventory of hazardous materials, as required by regulation 5 of the Annex to the Hong Kong Convention and by Article 9(1) of Regulation (EU) No 1257/2013, is an essential part of the International Certificate on Inventory of Hazardous Materials and must always accompany that certificate. Part I of the inventory of hazardous materials should be compiled on the basis of the standard format shown in the guidelines developed by the International Maritime Organization, supplemented, where applicable, by guidelines on aspects specific to Regulation (EU) No 1257/2013, such as substances listed in that Regulation but not in the Hong Kong Convention.

THIS IS TO CERTIFY:

1.	that the ship has been surveyed in accordance with regulation 10 of the Annex to the Hong Kong Convention, for those Member States that are parties to the Hong Kong Convention, and Article 8 of Regulation (EU) No 1257/2013; and

2.	that the survey shows that Part I of the inventory of hazardous materials fully complies with the applicable requirements of the Hong Kong Convention, for those Member States that are parties to the Hong Kong Convention, and Regulation (EU) No 1257/2013.

Completion date of survey on which this certificate is based: … (dd/mm/yyyy)

This certificate is valid until … (dd/mm/yyyy)

Issued at …

(Place of issue of certificate)

(dd/mm/yyyy) …	…
(Date of issue)	(Signature of duly authorized official issuing the certificate)

(Seal or stamp of the authority, as appropriate)

ENDORSEMENT TO EXTEND THE CERTIFICATE IF VALID FOR LESS THAN FIVE YEARS WHERE REGULATION 11.6 OF THE ANNEX TO THE HONG KONG CONVENTION AND ARTICLE 9(5) OF REGULATION (EU) No 1257/2013 APPLY  (*1)

The ship complies with the relevant provisions of the Hong Kong Convention, for those Member States that are parties to the Hong Kong Convention, and of Regulation (EU) No 1257/2013, and this certificate shall, in accordance with regulation 11.6 of the Annex to the Hong Kong Convention and with Article 9(5) of Regulation (EU) No 1257/2013, be accepted as valid until (dd/mm/yyyy): …

Signed: …

(Signature of duly authorized official)

Place: …

Date: (dd/mm/yyyy) …

(Seal or stamp of the authority, as appropriate)

ENDORSEMENT WHERE THE RENEWAL SURVEY HAS BEEN COMPLETED AND REGULATION 11.7 OF THE ANNEX TO THE HONG KONG CONVENTION AND ARTICLE 9(4) OF REGULATION (EU) No 1257/2013 APPLY (*)

The ship complies with the relevant provisions of the Hong Kong Convention, for those Member States that are parties to the Hong Kong Convention, and of Regulation (EU) No 1257/2013, and this certificate shall, in accordance with regulation 11.7 of the Annex to the Hong Kong Convention and with Article 9(4) of Regulation (EU) No 1257/2013, be accepted as valid until (dd/mm/yyyy): …

Signed: …

(Signature of duly authorized official)

Place: …

Date:(dd/mm/yyyy) …

(Seal or stamp of the authority, as appropriate)

ENDORSEMENT TO EXTEND THE VALIDITY OF THE CERTIFICATE UNTIL REACHING THE PORT OF SURVEY OR FOR A PERIOD OF GRACE WHERE REGULATION 11.8 OR 11.9 OF THE ANNEX TO THE HONG KONG CONVENTION AND ARTICLE 9(7) OR (8) OF REGULATION (EU) No 1257/2013 APPLY (*)

This certificate shall, in accordance with regulation 11.8 or 11.9 (*2) of the Annex to the Hong Kong Convention, for those Member States that are parties to the Hong Kong Convention, and with Article 9(7) or 9(8) (**) of Regulation (EU) No 1257/2013, be accepted as valid until (dd/mm/yyyy): …

Signed: …

(Signature of duly authorized official)

Place: …

Date: (dd/mm/yyyy) …

(Seal or stamp of the authority, as appropriate)

ENDORSEMENT FOR ADDITIONAL SURVEY WHERE REGULATION 10 OF THE ANNEX TO THE HONG KONG CONVENTION AND ARTICLE 9(2) OF REGULATION (EU) No 1257/2013 APPLY (*)

At an additional survey in accordance with regulation 10 of the Annex to the Hong Kong Convention, for those Member States that are parties to the Hong Kong Convention, and with Article 8(6) of Regulation (EU) No 1257/2013, the ship was found to comply with the relevant provisions of the Hong Kong Convention and Regulation (EU) No 1257/2013.

Signed: …

(Signature of duly authorized official

Place: …

Date: (dd/mm/yyyy) …

(Seal or stamp of the authority, as appropriate)