VOMS-PR1.

02-IN-02-015 Revision 4
Garbage Receipt Form Page 1 of 1

A – Description of Waste

Waste streams removed (M³)

Cat A Plastics 1 M³

Cat B Food waste M³

Cat C Domestic waste 4 M³

Cat D Cooking Oil 20 Ltr

Cat E Incinerator ashes M³

Cat F Operational wastes M³

Cat I E-Waste M³

Sludge M³

Dirty Oil M³

Oily Bilge water M³

Loose o Skips o Sacks X

Containment of waste Drums o Palletized o IBC o
Iso Tanks o Other o Other o

Total Quantity (M³) 5 M³ Estimated o Real o

B - Waste carrier
Company name :

Full name :

Address

C - Transfer of waste
Place of transfer Surabaya Channel
Date of transfer 22-10-2018
Method of waste transport : Truck o Pick-up o Vessel X

Destination of waste:
Producer Representative Receiver Representative
Name : R. Wijnia Name :
Date : 22-10-2018 Date : 22-10-2018
Signature : Signature:

Note: Categories G – Animal carcasses, H – Fishing gear, J – Cargo residues (non-HME) and K –
Cargo residues (HME) not applicable to van Oord operations