| (Issuing
authority)
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Copy to: Master
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| (Address)
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| (Telephone)
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| (Telefax)
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| (Email)
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| 1
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Reporting country
......................................................................................................
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| 2
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Name of ship
.............................................................................................................
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| 3
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Flag of ship
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| 4
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Type of ship
...............................................................................................................
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| 5
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Call sign
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6
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IMO number
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| 7
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Gross tonnage
....................................
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8
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Deadweight
..................................
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(where appropriate)
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| 9
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Year of build
.......................................
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10
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Classification society
....................
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| 11
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Date of incident
...................................
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12
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Place of incident
...........................
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| 13
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Date of
investigation
..................................................................................................
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| 14
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In
case of contravention of discharge provisions, a report may be
completed in addition to a port State report on deficiencies. This
report should be in accordance with parts 2 and 3 of appendix 3
and/or parts 2 and 3 of appendix 4, as applicable, and should be
supplemented by documents such as:
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.1 a statement by the observer of the pollution;
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.2 the appropriate information listed under section 1 of
part 3 of appendices 3 and 4 to the Procedures; the
statement should include considerations which lead the
observer to conclude that none of any other possible
pollution sources is in fact the source;
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.3 statements concerning the sampling procedures both of
the slick and on board; these should include location
where and time when samples were taken, identity of
person(s) taking the samples and receipts identifying
the persons having custody and receiving transfer of the
samples;
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.4 reports of analyses of samples taken of the slick and
on board; the reports should include the results of the
analyses, a description of the method employed,
reference to or copies of scientific documentation
attesting to the accuracy and validity of the method
employed and names of persons performing the analyses
and their experience;
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.5 if applicable, a statement by the PSCO on board
together with the PSCO's rank and organization;
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.6 statements by persons being questioned;
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.7 statements by witnesses;
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.8 photographs of the slick; and
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.9 copies or printouts of relevant pages of Oil/Cargo
Record Books, logbooks, discharge recordings, etc.
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Name and title (duly authorized contravention
investigation official)
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......................................................................................................................
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......................................................................................................................
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......................................................................................................................
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......................................................................................................................
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| Signature
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