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Vessel certification form.

Washington State Board of Pilotage Commissioners
Date:
Vessel Name:
Flag:
MASTER'S CERTIFICATION
I, . . . . . . . . . . ., Master of this vessel, certify the following information:
 
Yes
No
Is the engine room properly staffed, the engine able to maneuver, and all related equipment in good order?
Does this ship meet United States Coast Guard regulations governing safety and navigation?
Does this vessel comply with current international agreements governing safety and radio equipment?
Is this vessel leaking oil?
Is this vessel experiencing propulsion or maneuvering difficulties?
I have notified the United States Coast Guard Captain of the Port of any deficiencies noted above and he has authorized the vessel to proceed. Any such deficiencies will be corrected before the time the vessel is scheduled to leave the waters of Washington state.
 
. . . . 
 
Master's Signature
PILOT'S REPORT
I, . . . . . . . . . . ., a pilot licensed by the state of Washington, certify that upon boarding the above-named vessel on this date I requested to see the following certificates:
CERTIFICATE
ACCEPTABLE
NOT READILY
AVAILABLE
UNACCEPTABLE
SOLAS Certificate
FMC Certificate of
Financial Responsibility
 
. . . . 
 
Pilot's Signature
DEAD SHIP MOVEMENT
I, . . . . . . . . . . , owner, master, or agent's representative of this vessel, certify the following information:
 
Yes
No
Is the vessel leaking oil?
Are the lights per COLREGS?
Are thru hull fittings secured?
Is the vessel in all respects seaworthy for transit?
 
 
. . . . 
 
Owner, Master, or
Agent's Representative
[WSR 97-08-042, recodified as § 363-116-2051, filed 3/28/97, effective 3/28/97. Statutory Authority: RCW 88.16.155(7). WSR 92-08-052, § 296-116-2051, filed 3/26/92, effective 4/26/92. Statutory Authority: RCW 88.16.035 and 88.16.155. WSR 83-16-032 (Order 83-4, Resolution No. 83-4), § 296-116-2051, filed 7/28/83. Statutory Authority: RCW 88.16.155. WSR 79-11-097 (Order 79-6, Resolution No. 79-6), § 296-116-2051, filed 10/29/79. Statutory Authority: RCW 88.16.035 and 88.16.155. WSR 78-09-057 (Order 78-2, Resolution No. 78-2), § 296-116-2051, filed 8/23/78.]
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