Kimberley Ports Authority - Bulks Transfer Permit

Section 1: Applicant Details

Name of Permit Applicant
(person undertaking work onsite)

Name:

Contact Number:

Company:

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

Name:

Contact No:

Email:

Date of application:

Section 2: Description of Location and Activity

Vessel Name:

Description of Works (including type of bulk being handled):

Quantity of product being transferred:

Section 3: Permit Dates

Permit Requested From:

TO

Section 4: Permit Conditions

Permit Applicant to tick yes, no or NA to the following

JHA/Procedure has been prepared and is available for the works, if not provide reasoning:

YesNoN/A

Will the area where bulk transfer is occurring be assessed for potential hazards,and cleared of any incompatible materials that may react during transfer?:

YesNoN/A

Will the area be barricaded/cordoned offand warning signs displayed?:

YesNoN/A

Is the person conducting the transfer suitably trained and competent?:

YesNoN/A

The required PPE has been identified and will be worn by all persons involved inthe activity:

YesNoN/A

Is a spill kit on standby at all times?:

YesNoN/A

Is the equipment you are using fit for purpose?:

YesNoN/A

Section 5: Permit 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 the company I represent/undertaking the work has satisfactory documented safe systems of work in place and that all permits and licences required are current. Once the permit is authorised ensure that step 8 is completed prior to commencement of activity.

Signature:

Use your mouse or finger to draw your signature above.

Position:

Name:

Date: