Special Purpose Facility Annual Inspection Template
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1____________________________________________________________________
5NR OPS-5
(Rev. 11/05)
SPECIAL PURPOSE FACILITY OFFER FOR USE
Member Name: _________________________________ EMPLID / Unit Number: _____________ / ___________
Phone Number: (____) _____________
Special Purpose Facility Annual Inspection – Required Items
Y / N
1. Registered in appropriate State
2. Manual propulsion (e.g. – oars, paddles
3. Dewatering device (e.g. – bucket, scoop, hand pump)
4. Three Type 4 (throwable) PFD’s
5. Class B fire extinguisher
6. Sound producing device (e.g. – whistle, air horn)
7. First aid kit
8. Storm light (battery powered)
9. Three dock lines (minimum 20ft length; eye spliced on one end)
Special Purpose Facility Annual Inspection – Optional Items
Y / N
1. Outboard/electric motor (must have kill switch)
2. VHF radio or cellular phone
Inspected by: ______________________________ Date: ________________________________________
1. I hereby offer the following vessel for use as a Special Purpose Facility on authorized Auxiliary missions:
a. Make: _____________ Model: _____________ Length: ______________ Draft: ______________
b. Registration Number: ______________________ Hull ID Number: ___________________________
c. Type of Propulsion: __________________________________________________________________
d. Location: __________________________________________________________________________
e. Trailerable: Y
N
2. When I am aboard as a crew member, I authorize any qualified member _________________ to operate this facility
under Coast Guard orders.
3. When I am not aboard, I authorize the following members to operate this facility under Coast Guard orders, contingent
on their status as current in their qualification:
a. Any currently qualified member of: ________________________________________________
b. Member Name / EMPLID: _______________________________________________________
c. Member Name / EMPLID: _______________________________________________________
d. Member Name / EMPLID: _______________________________________________________
4. This offer is valid for __________ months / one year from the date of facility inspection provided that it is accepted
for use and not otherwise specifically revoked by me.
_______________________________________________
(Member sign / forward to DIRAUX)
Date: _________________________
Accepted
Rejected (reason for rejection: ____________________________________________________________)
_______________________________________________
(DIRAUX sign / return to member, copy to FC / FSO-OP / ERC)
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Parent category: Medical