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REPORT ON ANNUAL TESTING OF DNV Id No:
406MHZ EPIRBS Job Id:
MSC.1/Circ. 1040 Rev-2 and SOLAS reg. IV/15.9 and Polar Code Ch. 10.3.2.1.1 Date of issue: (yyyy-mm-dd) The general part, plus either Ch. 1 or Ch. 2 of this report (depending on the installation date of the EPIRB) should be completed after successful testing of the EPIRB based on all relevant parts of MSC.1/Circ. 1040 Rev-2 and SOLAS reg. IV/15.9.
General Name of vessel: Call sign: MMSI number: IMO Number: EPIRB make and type: , EPIRB Serial No.: EPIRB No. (if more than one unit provided): Located in/on: Hydro-static Release Unit Make and type: , Hydro-static Release Unit Expiry date:
Main Free-float EPIRB (SOLAS Reg. IV/7.1.6) Manual EPIRB
Polar Code EPIRB Polar Code Ch. 10.3.2.1.1 Item Y N N/A 1 EPIRBs installed before 2022-07-01 and type approved based on IMO res. A.763(18) or IMO A.810(19); or If installed after 2022-07-01, but accepted by the flag to be type approved based on IMO A.810(19) 1.1 Expiry date of battery: 1.2 Transmitted MMSI No. (shall be the same as the ship’s MMSI No.): (Ref. National requirements): 1.3 When required by Flag, Transmitted call sign/Serial No: 1.4 User protocol and 15 Hexadecimal ID: , 1.5 Measured Frequency (406 MHz): 1.6 Emission on 121.5 MHz checked? 1.7 Location/mounted according to requirements? 1.8 Satisfactory result of visual inspection (of both EPIRB and lanyard)? 1.9 Satisfactory result of self test? 1.10 Operating Instructions available? 1.11 Is the EPIRB waterproof marked with the ship’s name, callsign, 15 HEX ID, MMSI no, serial no and battery expire date? 1.12 Is shore-based maintenance in accordance with MSC Circ. 1039 carried out by authorized company, a report provided onboard and the unit been labelled accordingly? 1.13 Date for next shore-based maintenance: 2 EPIRBs installed on or after 2022-07-01 and type approved based on IMO res. MSC.471(101) 2.1 Expiry date of battery:
Form code: CRC 401 Revision: 2022-12 www.dnv.com Page 1 of 2
DNV Id No: Job Id:
Item Y N N/A 2.2 Transmitted unique beacon identification code: Note: (Unless specified otherwise by the flag, ref. National requirements): For first-generation beacons (type approved based on C/S T.001): MMSI, or MID + Serial. No., or MID + call sign. For second-generation beacons (type approved based on C/S T.018): MID + Serial. No. + MMSI, or MID + Serial. No. call sign. 2.3 User protocol and Hexadecimal ID (15 Hex ID for first-generation beacons and 23 Hex ID for second-generation beacons): , AIS identiy included in the Hexadecimal ID: 2.4 Type of GNSS system: GNSS system self test passed? Proper emission on the appropriate AIS frequencies? 2.5 Measured Frequency (406 MHz): 2.6 Emission on 121.5 MHz checked? 2.7 Location/mounted according to requirements? 2.8 Satisfactory result of visual inspection (of both EPIRB and lanyard)? 2.9 Satisfactory result of self test? 2.10 Operating Instructions available? Pictorial instructions for manual operation visible at the location of the beacon: 2.11 Is the EPIRB waterproof marked with the ship’s name, callsign, 15 Hex ID for first- generation beacons and 23 Hex ID for second-generation beacons, the AIS identity (User ID) if applpicable, MMSI no, Serial No. and battery expire date? 2.12 Is shore-based maintenance in accordance with MSC Circ. 1039 carried out by authorized company, a report provided onboard and the unit been labelled accordingly? 2.13 Date for next shore-based maintenance: 2.14 Registration in an appropriate beacon registration database? 2.15 MID, MMSI number or radio call sign, if encoded in the beacon, corresponds with that assigned to the ship?
Issued at (place) on (yyyy-mm-dd)
Approved Radio Firm (stamp)
(name) Radio Surveyor
Note: 1) The original of this document to remain on the vessel; and a copy to be attached to CRC 521 or POL CRC 521 (when the EPIRB used for compliance with Polar Code requirements)
Form code: CRC 401 Revision: 2022-12 www.dnv.com Page 2 of 2
