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)

Name*

Contact Number*

Email*

Company*

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

Name

Contact Number

DESCRIPTION OF LOCATION AND ACTIVITY

Vessel name*

Description of works*
(Including Type Of Bulk Being Handled)

Quantity of product being transferred*

PERMIT DATES

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

Start Date*

Start Time*

End Date*

End Time*

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.*

YesNo

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

YesNo

Will the area be barricaded/cordoned off and warning signs displayed?*

YesNo

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

YesNo

The required PPE has been identified and will be worn by all persons involved in the activity.*

YesNo

Will a spill kit on standby at all times?*

YesNo

Is the equipment you are using fit for purpose?

YesNo

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.

Name

Signature

Position

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

Bulks Transfer Permit

APPLICANT DETAILS

DESCRIPTION OF LOCATION AND ACTIVITY

PERMIT DATES

PERMIT CONDITIONS

APPLICANT STATEMENT OF ACKNOWLEDGEMENT

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