CG77 POLREP Pollution Report Form

To: MCA, London-MRCC
Copy to: Agencies as required
From: Royal Docks Waterways (RDW)

Classification report

Classification report Doubtful Probable Confirmed
Date of Incident Date of Incident / DD / MM YYYY
Time of Incident Time of Incident : HH MM AM/PM
Name of observer/reporter Name of observer/reporter First Last
Position of Pollution

Latitude/Longitude, Range and bearing from prominet point of land.
Extent of pollution in litres/barrels, tonnes.
Size of polluted area.
Wind Speed (knots) and direction.
Tidal status at time of pollution (after/before HW/LW)

Tidal status at time of pollution (after/before HW/LW) Ebb Tide Flood Tide N/A Other
Weather Conditions.
Sea State
Wave Height (meters)
Type of pollution

Crude, Diesel, Garbage etc.
Appearance of Pollution

Liquid, Solid Sludge etc
Source of pollution (if known)

From a vessel or other
Cause of pollution (if Known)

Apparent deliberate discharge or casualty. If the latter give a brief description. where possible name, type, size, nationality and Port of Registry of Polluting vessel. if Vessel underway, give course, speed and destination (if known).
Details of any vessel in the area.

to be given if the polluter cannot be identified and the spill is considered to be of recent origin.
Photographs taken

Photographs taken Yes No
Upload an pictures takens
Upload an pictures takens
Upload an pictures takens
Upload an pictures takens
Upload an pictures takens
Sample taken for analysis

Sample taken for analysis Yes No
Forecast of likely effected of pollution

e.g. arrival on coastline with estimated timing.
Details of and Remedial action taken/intended to deal with the spill.
Names of those informed other than addresses
Any other relevant information

e.g. names of other witnesses, references to other instance of polution pointing to source.