INTERNATIONAL NAVAL SURVEYS BUREAU

REPORT OF SURVEY OF ANTI-FOULING SYSTEM ON SHIPS

To meet Regulations of ANNEX I of the International Convention for the

Prevention of Pollution from Ships, 1973 and its 1978 Protocol, as amended.

Initial Survey / Renewal Survey / Unscheduled Survey
Name of Ship : / Distinctive Letters : / Port of Registry:
Gross Tonnage: / Dead Weight (metric tons): / Year of Build:
Managers (or agents) :
Place of survey: / in dry-dock / on slipway / afloat / Survey Commenced :
At: / Survey Completed :
Note: / i.  Fields should be filled with YES, NO or N/A as required.
ii.  All negative entries (NO) should be clarified under "Surveyor's Notes" with reference by item number.
I.  GENERAL INFORMATION
1. / Has the vessel a valid certification by a recognized society for AFS compliant to the AFS Convention? / YESNON/A
If yes indicate issuance authority and certificate number:
2. / Has the paint manufacturer given documentation for the AFS to be applied not to contain, prohibited / regulated
compounds, Material Safety Data Sheet (MSDS) or similar with active ingredients and CAS No? / YESNON/A
II.  INFORMATION RELATED TO SEALER COAT
3.1 / Has a sealer coat system been applied to cover non-compliant AFS? / YESNON/A
(not needed if old AFS is removed, proceed to paragraph 4.)
Verified by survey / or Attestation
Indicate name of sealer coat:
Indicate date of application :
Indicate manufacturer name:
3.2 / Has the sealer coat a colour specified that is different from the underlying non-compliant AFS? / YESNON/A
Indicate colour of sealer coat.
Indicate colour of old underlying non-compliant AFS.
3.3 / Has the paint manufacturer given an attestation that the sealer coat forms a barrier to leaching from / YESNON/A
the underlying AFS. (same to be attached herewith)
III.  INFORMATION RELATED TO AFS SYSTEM
4. / Has the non-compliant AFS been adequately removed e.g. blast cleaning, hydro blasting or other, if relevant? / YESNON/A
Verified by survey / or Attestation
5. / Has the AFS specified by the ship owner been applied to the ships? / YESNON/A
(Also same name on container and MSDS or similar)
Verified by survey / or Attestation
6.1 / Name of applied AFS on Side bottom plating / YESNON/A
Type:
Colour:
Anti-fouling system manufacturer(s)
6.2 / Name of applied AFS on Flat bottom plating (if different from above) / YESNON/A
Type:
Colour:
Anti-fouling system manufacturer(s)
6.3 / Are the AFSs' of Type Approved by an IACS society. / YESNON/A
(In affirmative case, sample verifying that AFS is TBT-Free not required, otherwise proceed to paragraph 7)
Date(s) of application of anti-fouling system
Name(s) of company(ies) and facility(ies) / location(s) where applied.
IV.  Sampling of AFS (Applicable if required verification of AFS compliance)
7. / Collection / Sampling has been taken by laboratory(ies) approved by an IACS society. / YESNON/A
Attached approval certificate of the laboratory. / Attached analysis report of the AFS

V.  SURVEYOR'S NOTES

VI.  CERTIFICATE
The AFS Certificate with No. / was endorsed issued on / YESNON/A
An AFS Declaration with No. / was endorsed issued on / YESNON/A
Date:
Surveyor to International Naval Surveys Bureau - I.N.S.B.

Form 1215225-AFS/01-2012 Page 2 of 2