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Dept.of Hampland Security SLE Activity No , <br /> U.S.COAST GUARD Part State Control Report of Inspection - FORM A* �C Ca <br /> � <br /> CG-5437A(5-2004} In accordance with IMO Port State Control Procedures Activity Tune: <br /> (Resolution A.787(19),as amended by Resolution A.882(21)) <br /> and the International Ship&Portfacility Security(ISPs)Code <br /> 1. Reporting Country: United States of America 2.Name of Ship: CA N5. <br /> 3.Flag of Ship: ��yNn_fn 4.Ship Type IMO Code: ll Siyti: 3 <br /> 6.IMO Number7.Gross Tonnage: 8. Deadweight(where applicable): <br /> 9.Year of Build: 10.Date of Inspection-.5koc_<AKL� Cry 4i'• Place of Inspection: C� <br /> 12.Classification Society: 13. Date of release from detention": <br /> 4. Ship Management Information: <br /> COF plicant: <br /> Charterer: <br /> ISM DOC Company: <br /> Owner/Operator(if different COFR or DOC): <br /> 15.Relevant Certificates/Documents <br /> b)issuing authority c)dates of issue and ex <br /> a)name <br /> 1) <br /> 3) <br /> 5) <br /> 6) <br /> 7) <br /> d)information on last intermediate or annual surveylaudit" <br /> date surveyinglauditing authority place <br /> 1} <br /> 2) <br /> 3) <br /> W Z <br /> .,1 < 4) — <br /> m 0 5) <br /> 'N o 6) <br /> (3 7) <br /> Circle all applicable parts for 16-19 beton: <br /> 16.Deficiencies Identified: ro Yes (if yes circled,see Form B(CG-54378)) <br /> 17.Major Control Action: (Z;) Detention Expulsion Denial of Entry <br /> 18. Priority: PI PC, NPV TSPS I ISPs II ISPS III Random <br /> 19. Drills Conducted? No ire Drill Abandon Ship Drill ISPS/Security Related Drill <br /> Copy provided to: !`� <br /> (printed name of Master/Vessel representative) (Signature) <br /> Name of PSCO: A c-\ t <br /> (printed name of duly uthorized PSCO of reporting authority) nature) <br /> Issuing Unit Name and Address: �—� "31 o Ul Copies forwarded to: --- <br /> Check as appropriate Reviewed by Supervisor: <br /> COMMANDER _Agent (print name,sign and date) <br /> g Ste <br /> USCG SECTOR SAN FRANCISCO —Fla <br /> zed Organization <br /> CG ISLAND, BLDG.14 _RSO <br /> ALAMEDA, CA 94501-5100 _Ship Management <br /> Phis inspection report has been issued solely for the purpose of in1'om�inn the master and other port States that an inspection by the port State,mentioned in die.heading,has taken place.This inspection i <br /> construed as a seaworthiness certificate in excess of the certificate the ship is required to carry. <br /> Page_ <br /> *$ To be completed in the event of a detention. <br /> Vessel Copy <br />