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 requested for
(to be filled out by permit applicant)
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:
- have safe systems of work in place;
- use equipment that is certified (when required) and fit for purpose;
- be competent in the type of work being undertaken; and
- hold all required permits and licenses.
*There are errors on the form. Please check entered values.