< Previous App 1-38 Environmental Technical Manual 1.3 TEMPLATE OF CORSIA ELIGIBLE FUELS SUPPLEMENTARY INFORMATION TO THE EMISSIONS REPORT (FROM AEROPLANE OPERATOR TO STATE) This section provides a template version of the reporting requirements as described in Annex 16, Volume IV, Appendix 5, Table A5-2. (*supplementary information to the Emissions Report from aeroplane operator to State)Template InformationTemplate provided by:Version (publication date):CORSIACONTENTSCORSIA ELIGIBLE FUELS SUPPLEMENTARY INFORMATION*Summary of CORSIA eligible fuels informationCORSIA eligible fuel claim formAeroplane operator identification and reporting informationTemplate informationVolume IV. Procedures for demonstrating compliance with the Carbon Offsetting and Reduction Scheme for International Aviation (CORSIA) Appendix 1 App 1-39 a)Name of aeroplane operatorPlease enter the name of the aeroplane operator. This name should be the legal entity carrying out the aviation activities.a1) Address of the aeroplane operatorb)Reporting yearCountry:City:State/Province/Region:Postcode/ZIP:AEROPLANE OPERATOR IDENTIFICATION AND REPORTING INFORMATIONPlease enter the address of the aeroplane operator.Address: App 1-40 Environmental Technical Manual Note: for each claim of emissions reductions from the use of CORSIA eligible fuels, please replicate this form and fill separately.Fuel Claim #:a)Purchase datePlease enter the date when the neat CORSIA eligible fuel was purchased. Use the format yyyy-mm-dd.b)Identification of the producer of the CORSIA eligible fuel b1)Name of producer of the neat CORSIA eligible fuelPlease enter the name of the fuel producer.b2)Address of the producer of the neat CORSIA eligible fuelc)Fuel productionc1)Date of production of the neat CORSIA eligible fuelPlease enter the date of production of the neat CORSIA eligible fuel. Use the format yyyy-mm-dd.c2)Location of the production of the neat CORSIA eligible fuelc3)Batch identification number:c4)Mass of each batch of neat CORSIA eligible fuel producedPlease enter the total mass of each batch of neat CORSIA eligible fuel produced (in tonnes).State/Province/Region:Postcode/ZIP:Please enter the address of the production of the neat CORSIA eligible fuel.Address:City:CORSIA ELIGIBLE FUEL CLAIM FORMPostcode/ZIP:Country:Please enter the address of the producer of the neat CORSIA eligible fuel.Address:City:State/Province/Region:Country:Volume IV. Procedures for demonstrating compliance with the Carbon Offsetting and Reduction Scheme for International Aviation (CORSIA) Appendix 1 App 1-41 d)Fuel typed1)Type of fuelPlease enter the type of fuel (i.e., Jet-A, Jet-A1, Jet-B, AvGas) for the purpose of computation of Life Cycle Emissions factors.d2)Feedstock typePlease enter the information on the feedstock used to create the neat CORSIA eligible fuel.d3)Conversion processPlease enter the conversion process (i.e., a type of technology used to convert a feedstock into neat CORSIA eligible fuel).d)Portion of batch purchased (if needed)d1)Percentaged2)Mass of batch purchasedPlease enter the mass of CORSIA eligible fuel batch purchased (in tonnes).e)Mass of neat CORSIA eligible fuelPlease enter the total mass of all batches of neat CORSIA eligible fuel included in the claim (in tonnes).f)Sustainability documentationPlease provide evidence that the fuel satisfies the CORSIA Sustainability Criteria i.e., reference of attached valid certification document.g)Life Cycle Emissions Values of the CORSIA eligible fuelg1)Default or Actual Life Cycle Emissions value (LSf) Please enter the Life Cycle Emissions value (in gCO2e/MJ).g2)Default or Actual Core Life Cycle Assessment (LCA) valuePlease enter the Core Life Cycle Assessment (LCA) value (in gCO2e/MJ).g3)Default Induced Land Use Change (ILUC) valuePlease enter the Induced Land Use Change (ILUC) value (in gCO2e/MJ).If less than an entire batch of neat CORSIA eligible fuel is purchased, please enter the proportion of neat CORSIA eligible fuel batch purchased (in percentage terms). App 1-42 Environmental Technical Manual h)Intermediate purchaser 1 (if needed)h1)Name of the intermediate purchaser 1.Please enter the name of the intermediate purchaser 1.h2)Address of the intermediate purchaser 1.i)Intermediate purchaser 2 (if needed)i1)Name of the intermediate purchaser 2.Please enter the name of the intermediate purchaser 2.i2)Address of the intermediate purchaser 2.j)CORSIA eligible fuel shipperj1)Name of the CORSIA eligible fuel shipper.Please enter the name of the party responsible for shipping of the neat CORSIA eligible fuel to the fuel blender.j2)Address of the CORSIA eligible fuel shipper.If the aeroplane operator claiming emissions reductions from the use of CORSIA eligible fuels is not the original purchaser of the fuel from the producer (e.g., the aeroplane operator purchased fuel from a broker or a distributor), include the identity and contact information of these purchaser(s).City:Address:Please enter the address of the party responsible for shipping of the neat CORSIA eligible fuel to the fuel blender.Country:Postcode/ZIP:State/Province/Region:Postcode/ZIP:Country:Please enter the address of the intermediate purchaser 2.Address:City:Address:City:State/Province/Region:Postcode/ZIP:State/Province/Region:Please include the identity and contact information of the intermediate purchaser 2.Country:Please enter the address of the intermediate purchaser 1.Volume IV. Procedures for demonstrating compliance with the Carbon Offsetting and Reduction Scheme for International Aviation (CORSIA) Appendix 1 App 1-43 k)Fuel blenderk1)Name of the fuel blenderPlease enter the name of the party responsible for blending neat CORSIA eligible fuel with aviation fuel.k2)Address of the fuel blenderl)Location of blendingm)Neat CORSIA eligible fuel receivedm1)Date the neat CORSIA eligible fuel was receivedPlease enter the date the neat CORSIA eligible fuel was received by blender. Use the format yyyy-mm-dd.m2)Mass of neat CORSIA eligible fuel receivedPlease enter the mass of neat CORSIA eligible fuel received (in tonnes).n)Blend ratio of neat CORSIA eligible fuel and aviation fuelPlease enter the blend ratio of neat CORSIA eligible fuel and aviation fuel.o)Documentation demonstrating blendingp)Mass of neat CORSIA eligible fuel claimed Please enter the mass of neat CORSIA eligible fuel claimed (in tonnes).Please provide documentation demonstrating that the batch or batches of CORSIA eligible fuel were blended into aviation fuel (e.g., the subsequent Certificate of Analysis of the blended fuel).City:Address:Please enter the location where the neat CORSIA eligible fuel is blended with aviation fuel.Address:Please enter the address of the party responsible for blending neat CORSIA eligible fuel with aviation fuel.Country:Postcode/ZIP:State/Province/Region:Country:Postcode/ZIP:State/Province/Region:City: App 1-44 Environmental Technical Manual — END — a)Summary of CORSIA eligible fuels (by fuel claim #)Type of fuelFeedstock typeConversion process12345678910b)Summary of information of CORSIA eligible fuels claimedb1)Total of emissions reduction from CORSIA eligible fuels claimed (in tonnes)Please enter the sum of the values included in column "Emissions reduction from CORSIA eligible fuels claimed (in tonnes)" of the table abovePlease provide a summary of the CORSIA eligible fuels claimed for the reporting year.Fuel claim #SUMMARY OF CORSIA ELIGIBLE FUELS INFORMATIONTotal mass of neat CORSIA eligible fuel claimed (in tonnes)Life cycle emissions values of the CORSIA eligible fuelEmissions reduction from CORSIA eligible fuels claimed (in tonnes)Fuel type Next >