MARPOL Illegal Discharge Witness Statement

1. Witness Personal Information

Full Name Rank / Position Nationality Contact Information

2. Vessel Information

Vessel Name IMO Number Flag State

3. Incident Details

Date and Time of Incident Location (Lat/Long or Description) Nature of Discharge Observed Description of the Incident Persons Involved (if known) Equipment/Systems Used (if any)

4. Evidence

Description of Any Evidence (e.g. photos, recordings, log entries)

5. Additional Comments

Comments

6. Declaration

I hereby declare that the information provided above is true and accurate to the best of my knowledge. Signature Date