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U.S. Coast Guard
17
th
Coast Guard District







Un-Inspected Passenger Vessel (UPV)
and
5 Star Safety

Dockside Examination
Form








January 2008 Edition Vessel Name
Registration or Documentation #
Name: Owner Operator
Examination Date

Length
Beam
Draft
Net Tonnage
Year MFG.
Mailing Address
Vessel Color(s)

Hull Deck Super Structure

Vessel Make (MFG)


City, State, Zip.




Vessel Model:
Street Address if Different than Mailing
Work Phone Number
( )
Usage Fuel
Type
Horse-
power
Propulsion Type
City, State, Zip.

Cell or Home Number
( )

Email Addresses:



UPV



Gas


Diesel


Other



Inboard


Outboard

Sail

Operator U.S. Coast Guard License Number
Name of License Holder
Hull Identification Number
Operator US Coast Guard License Type
License Expiration Date:
Hull Structure

Home Port
Marina Slip #
Vessel Exam Location
Sector Command
Anchorage

Wood Fiberglass Steel
Aluminum


Juneau

Drug Testing
Consortium Name:
Charter Association Membership Information
Not a Member

Address:
Name
City/State/Zip
Address


Telephone:
Phone Number
Email Address
If available, Crewmember Names and Most Recent Drug Test Date

Name : Drug Test Date:

1. ________________________ _______________________

2. ________________________ _______________________

3._________________________ _______________________

4. ________________________ _______________________
UPV Decal Issued:
Yes No
5 Star Participan</b>t:
UPV Decal Number
: __________

Yes No


Initial Issue Renewal:
Number Stars Earned:

Issue Date:


Expiration Date:


Expiration Date: 31 December ________
31 December ______

A voluntary UPV dockside examination has been completed. However a UPV Safety Decal cannot be issued due to the following deficiencies: (note
deficiency by item number, with an explanation, and identify any Extremely Hazardous Conditions (EHC). Use additional sheet as required.
____________________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________
When these deficiencies are corrected, please call this number to schedule a re-examination:
Examiner Name: _________________________ Phone Number: __________________________


Congratulations! Your vessel is in compliance with all applicable UPV regulations. issued. The decal is valid for 2 years provided that all regulatory and
operating requirements remain current. Please keep this form on board and show it to the Coast Guard if the vessel is boarded.
I CERTIFY that I have personally examined the vessel and find it meets the requirements of this report at the time of the examination.
Examiner Printed Name: Issuing Examiner Signature: Examiner Unit:

By accepting this UPV decal I pledge to always maintain my vessel and equipment to the standard of safety qualified for during this examination. I will
remove this decal if the vessel is sold or the vessel no longer meets these requirements.

Vessel Representative Signature: ___________________________________________________________ Date:____________________

January 2008 Edition
USCGD17 UPV 5 Star Examination Form
Page 1/4

Comments or continued vessel or operator information: Page 2/4
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U.S. COAST GUARD 17 UPV FORM JANUARY 2008 U.S. Coast Guard UPV & 5 Star Marine Examination Check List
2/2007 Edition
Vessel Name: Date:
Page: 3 of 4

Subject Y
N
N/A
Subject
Y
N
N/A
1. DISPLAY OF NUMBERS, NAME,
MARKINGS: Name, hailing port, proper size, current
AK sticker. State vessels - 33 CFR 173, Documented
vessels - 46 CFR 67



15. FUEL SYSTEM: Tanks secure, Over 7 gallons are considered
permanent & must be grounded / vented. Approved hoses in good
condition, no leaks. 33 CFR 183. 514, .524, .528, & .572



2. NAVIGATION LIGHTS: Proper navigation
lights and all around anchor light. 33 CFR 84,
COLREGS 72



16. POLLUTION PLACARD: Vessels 26 ft. & over w/machinery
compartment. 33 CFR 155.450



3. SOUND PRODUCING DEVICE: Vessels less
than 12 m. or 39.4 ft. require means to make efficient
sound: whistle, horn, or other. 72 COLREGS Rule 33



17. ELECTRICAL SYSTEMS: Batteries secure, terminals covered,
well organized wiring, proper fuses/circuit breaker. 33 CFR 183.420




3a. SOUND PRODUCING DEVICE: Vessel 39.4 ft
/ 12m or greater, required to carry on board a whistle or
horn and a bell. 72 COLREGS Rule 33



18. MARINE SANITATION DEVICE (MSD)
Installed MSDs must be approved and operable, overboard discharge
secured by acceptable method. 33 CFR 159.7



4. REGISTRATION OR DOCUMENTATION



19. GALLEY / HEATING SYSTEMS: Secure system, proper tank
installation. No flammable material nearby. 46 CFR 25.45



Registration or Documentation must be current &
onboard. 46 CFR 67, 33 CFR 173



20. MARINE TRASH PLACARD: Must be displayed on vessels 26
ft. and over. 33 CFR 151.59



5. HULL IDENTIFICATION NUMBER or
OFFICIAL Number: HIN permanently marked: 33
CFR 181.23 or Official # permanently affixed- 46 CFR
67.121. If monohull < 20 ft, has CG Capacity Plate:
visible. 33 CFR 183.23
6. USCG LICENSE: On Board, Current, Licensed
for area of operation & tonnage. 46 CFR 15.605 &
.905; 46 CFR 26.20 & 15.401



21. OVERALL VESSEL CONDITION (Bilge & Equipment area
clean, well maintained. Not overloaded, overpowered, or NO
AUTOMOTIVE PARTS, USE MARINE PARTS ONLY.



7. TWO LICENSED OPERATORS. Operator aware
of requirement for adequate watches for voyages >12
hrs. 46 USC 8104(b).



22. CHARTS & PUBLICATIONS: International Rules apply.
C