(Revised 07/09) FORM NINTH DISTRICT DRAWBRIDGE SIGNALS OR OPERATION DELAYS TO: Commander (dpb) Ninth Coast Guard District 1240 E. 9th Street – Room 2047b Cleveland, Ohio 44199-2060 (216) 902-6087 fax: (216) 902-6088 E-Mail: William.B.Stanifer@uscg.mil Scot.M.Striffler@uscg.mil Lee.D.Soule@uscg.mil DATE: ___________________________ NOTE: Reports of Delay will be processed only when all items are fully addressed and reports are submitted within 15 days of reported delay / difficulty. CONFIDENTIALITY: Please check here if you wish to keep names of vessels and persons confidential ( ). Please forward report to address, fax number or email above. When emailing, please “address” to Scot M. Striffler and “copy” to William B. Stanifer and Lee D. Soule. 1. NAME OF VESSEL: ______________________________ 2. PORT: __________________________________________ 3. DATE OF DELAY: _______________ ( ) INBOUND ( ) OUTBOUND 4. BRIDGE NAME: _______________________________ 5. WATERWAY: ______________ MILE: ________ (Bridge name, waterway, and mile from Coast Pilot #6) NOTE: IF DELAY IS AT RAILROAD BRIDGE, AND TRAINS ARE "CONTINUOUSLY" BEING RUN ACROSS OR STOPPED ON A DRAWBRIDGE, PLEASE INDICATE ON REVERSE SIDE OF FORM THE STARTING AND ENDING TIMES FOR EACH TRAIN, OR TIMES THAT TRAINS ARE STOPPED ON BRIDGE. 6. IF ADVANCE NOTICE IS PROVIDED, TIME NOTICE GIVEN: _________ ETA PROVIDED: __________ TO WHOM: ______________________ 7. TIME FIRST SIGNAL GIVEN FOR BRIDGE: _____ TIME ARRIVED AT BRIDGE: _____ 8. TIME FIRST SIGNAL RECEIVED FROM BRIDGE: _______ (Did response indicate immediate opening could be expected or that there would be a delay?) ______________________________________________________________________________ ______________________________________________________________________________ 9. TIME BRIDGE OPENED: _______ TIME LOST: ________ 10. WHAT WAS REASON PROVIDED FOR DELAY?: ________________________________ ____________________________________________________________________________ 11. WHAT NAVIGATIONAL OR MANEUVERING DIFFICULTIES WERE CAUSED BY DELAY?: ______________________________________________________________________________ 12. PRINTED OR TYPED NAME AND ADDRESS OF REPORTING SOURCE: ___________________________________ 13. PHONE NUMBERS AND/OR E-MAIL ADDRESS (FOR ADDITIONAL QUESTIONS BY COAST GUARD AND FOR FINAL STATUS OF REPORT): ___________ __________________________________ ____________________________ (SIGNATURE)