This document is a certificate of inspection from the United States Coast Guard for a vessel. It lists the vessel's particulars including licensed and unlicensed crew positions, inspection and certification details, permitted routes and operating conditions, lifesaving equipment requirements, and firefighting equipment requirements. The Coast Guard officer certifies that the vessel conforms to all applicable laws and regulations.

1. Masters
Chief Mates
Second Mates
Third Mates
Master First Class Pilots
Mate First Class Pilots
Licensed Mates
First Class Pilots
Radio Officers
Able Seamen
Ordinary Seamen
Deckhands
Chief Engineers
First Assistant Engineers
Second Assistant Engineers
Third Assistant Engineers
Licensed Engineers
Non Licensed Engineer Depts
Qualified Member
Engineer Depts
Oilers
Crew Members
OperatorOwner
Gross TonsDelivery Date Keel Laid Date Net Tons
R- R-
I-
DWT Length
R-
I-I-
Place Built
Hull Material Horsepower Propulsion
Hailing Port
Vessel Name IMO Number Call Sign ServiceOfficial Number
In addition, this vessel may carry Passengers, Other Persons in crew, Persons in addition to crew, and no Others. Total
Persons allowed:
With this Inspection for Certification having been completed at UNITED STATES, the Officer in Charge, Marine
Inspection, Sector certified the vessel, in all respects, is in conformity with the applicable vessel
inspection laws and the rules and regulations prescribed thereunder.
This vessel must be manned with the following licensed and unlicensed Personnel. Included in which there must be Certified
Lifeboatmen, Certified Tankermen, HSC Type Rating, and GMDSS Operators.
Annual/Periodic/Re-Inspection This certificate issued by:
Officer in Charge, Marine Inspection
Inspection Zone
Date Zone A/P/R Signature
Route Permitted And Conditions Of Operation:
***SEE NEXT PAGE FOR ADDITIONAL CERTIFICATE INFORMATION***
OMB Approved No. 1625-0057Dept. Of Home Sec., USCG - CG-854 (Rev. 06-04) Page 1 of 3
This Temporary Certificate of Inspection is issued under the provision of Title 46 United States Code, Section 399, in lieu of the regular certificate of inspection, and shall be in force only until the
receipt on board said vessel of the original certificate of inspection, this certificate in no case to be valid after one year from the date of inspection.
United States of America
Department of Homeland Security
United States Coast Guard
For ships on international voyages this certificate fulfills the requirements of SOLAS 74 as amended, regulation V/14, for a SAFE MANNING DOCUMENT.
Certification Date:
Expiration Date:
C. O. Theport, Captain, U. S. Coast Guard
Sector Upper Mississippi River

2. OMB Approved No. 1625-0057Dept. Of Home Sec., USCG - CG-854 (Rev. 06-04) Page 2 of 3
Vessel Name:
United States of America
Department of Homeland Security
United States Coast Guard
Certification Date:
Expiration Date:

3. OMB Approved No. 1625-0057Dept. Of Home Sec., USCG - CG-854 (Rev. 06-04) Page 3 of
Vessel Name:
United States of America
Department of Homeland Security
United States Coast Guard
Certification Date:
Expiration Date:
---Hull Exams---
Exam Type Next Exam Last Exam Prior Exam
DryDock
Internal Structure
--- ---
--- Inspection Status ---
Pressure Vessels*
Location Previous Last Next
Quantity Capacity Required
Life Preservers (Adult)
Life Preservers (Child)
Ring Buoys (Total)
With Lights
With Line Attached
Other
Immersion Suits
Portable Lifeboat Radios
Equipped With EPIRB?
Manufacturer:
---Lifesaving Equipment---
Total Equipment for Persons Primary
Lifesaving Equipment
Lifeboats (Total)
Lifeboats (Port)
Lifeboats (Starboard)
Motor Lifeboats
Lifeboats With Radio
Rescue Boats/Platforms
Inflatable Rafts
Life Floats/Buoyant App
Inflatable Buoyant Apparatus (IBA)
--- Fire Fighting Equipment
Quantity Diameter Length
9

4. ***END***
OMB Approved No. 1625-0057Dept. Of Home Sec., USCG - CG-854 (Rev. 06-04) Page of
Vessel Name:
United States of America
Department of Homeland Security
United States Coast Guard
Certification Date:
Expiration Date:
*Fire Extinguishers - Hand portable and semi-portable*
Quantity Class Type
Number of Fireman Outfits - Number of Fire Pumps -