Kimberley Ports Authority

Section 1: Applicant Details

Name of Permit Applicant
( person undertaking work onsite )

Permit Applicant Name:

Permit Applicant Contact No:

Email:

Company:

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

Name:

Contact No:

Section 2: Description of Location,Activityand person in charge of bunker delivery

Vessel Name or Site Location:

Description of fuel type:

Quantity being transferred:

Method of bunkering:

Name, Induction Number and expiry date:

Direct all cabinet bowser enquires to Broome Bunkering Services - mobile 0499 789 998

Section 3: Bunkering Permit Dates

Permit From:

TO

Section 4: Permit Conditions

Permit Applicant to tick agree or not agree to the following

JHA/Procedure has been prepared and is available for the works:

AgreeNot Agree

The area where bunkering is occurring will be assessed for potential hazards. All sources of ignition are clear of the 8 m isolation zone around the discharge point. Intrinsically safe electrical equipment only within this zone. (No ULP, Jet A1 bunkering at Berth 1 and 2 unless inner berth blocked off):

AgreeNot Agree

The area will be barricaded and warning signs displayed:

AgreeNot Agree

The person conducting the bunkering is competent, suitably trained (inducted)and is accompanied by valid certification and Safety Data Sheet of the bunkered product.(DG Licence required for Class 3 products):

AgreeNot Agree

The required PPE has been identified and will be worn by all persons involvedin the activity:

AgreeNot Agree

A spill kit and firefighting equipment is on standby at all times?:

AgreeNot Agree

The equipment you are using is fit for purpose, meets the Aust. Standard and is accompanied by valid test certificates?:

AgreeNot Agree

Section 5: 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:

Bunker Permit