Bulks Transfer Permit

This form is for the purpose of obtaining permission to conduct bulk transfers and to ensure that hazards associated with this work activity are controlled. *Mandatory fields.

APPLICANT DETAILS

Name of Permit Applicant
(person undertaking work onsite)


Company representative/contact filling out permit
(if different to permit applicant)


DESCRIPTION OF LOCATION AND ACTIVITY


PERMIT DATES

Permit requested for
(to be filled out by permit applicant)

:
:

PERMIT CONDITIONS

Permit Applicant to tick yes or no to the following

JHA/Procedure has been prepared and is available for the works, if not provide reasoning.*
Will the area where bulk transfer is occurring be assessed for potential hazards, and cleared of any incompatible materials that may react during transfer?*
Will the area be barricaded/cordoned off and warning signs displayed?*
Is the person conducting the transfer suitably trained and competent?*
The required PPE has been identified and will be worn by all persons involved in the activity.*
Will a spill kit on standby at all times?*
Is the equipment you are using fit for purpose?

APPLICANT STATEMENT OF ACKNOWLEDGEMENT

I acknowledge the requirements of the Kimberley Ports Authority to identify and control risks and work in a safe manner at all times.

I confirm in undertaking this work the company or I have:

  1. have safe systems of work in place;
  2. use equipment that is certified (when required) and fit for purpose;
  3. be competent in the type of work being undertaken; and
  4. hold all required permits and licenses.
 

 

*There are errors on the form. Please check entered values.