Fillable Marine Pollution Report (POLREP) (Services Australia)

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Marine Pollution Report (POLREP) (Services Australia)

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The Marine Pollution Report (POLREP) (Services Australia) form is 2 pages long and contains:

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  • 31 check-boxes
  • 55 other fields

Country of origin: AUSTRALIA
File type: PDF

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Department of
Transport
BEFORE completing this form please contact the
MEER duty officer on (08) 9480 9924 (24hrs).
Immediate reporting will enable a rapid response.
INCIDENT DETAILS
Marine Pollution Report (POLREP)
Date of Incident: Time of Incident (24 hr format):
Return completed form to:
Maritime Environmental Emergency Response
Department of Transport
Email: marine.pollution@transport.wa.gov.au and rccaus@amsa.gov.au
Phone (08) 9480 9924
Fax: (08) 94357807
Location name/description:
Incident Coordinates
Latitude of spill Longitude of spill
Format of coordinates used (select one) Degrees & decimal degrees Degrees, minutes & decimal minutes Degrees, minutes &
seconds
Description of Incident:
POLLUTION SOURCE
Vessel Land (Specify) Other (Specify) Unknown
Vessel type (if known) Tanker Container Bulk Cargo
Fishing Defence Recreational Other (Specify)
Vessel name: Flag State / Callsign: Australian vessel? Yes No
POLLUTANT
Oil (type) Bilge Diesel HFO bunker Crude Unknown Other (Specify)
Chemical Name: MARPOL cat / UN Nos:
Garbage Details/description:
Packaged Details/description:
Sewage Details/description:
Other Details/description:
EXTENT
Size of spill (length & width in metres):
Amount of pollutant, if known (litres):
Has the discharge stopped? Yes No Unknown
Weather conditions at site:
Photos taken Details: held by:
Video taken Details: held by:
Samples taken Description: held by:
Items retrieved Description: held by:
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ADDITIONAL INFORMATION
Response action undertaken? Yes No If yes, provide details below, please include any environmental impact.
Equipment used? AMSA State / NT Industry
Is assistance for an investigation required from DoT Yes No
ORIGINAL REPORT SOURCE
Name: Position: Phone:
Combat agency: Statutory agency:
SENDER DETAILS
Name: Agency: Date:
Phone: Fax: Email:
PRIVACY STATEMENT
The Department of Transport is collecting the information on this form to enable it to carry out its role as Jurisdictional Authority as per WestPlan - Marine Oil Pollution.
The Department of Transport and/or AMSA may give some or all of this information to other government bodies, non-government organisations who have responsibilities under
the National Plan, and law enforcement agencies.
Once you have completed the form please check that all relevant fields have
been filled with accurate data.
Please email completed form to marine.pollution@transport.wa.gov.au
mep_polrep_0815
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Marine Pollution Report (POLREP) (Services Australia)

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Completed 20 May 2022

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