Port of Derby 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.

This field is for validation purposes and should be left unchanged.

Applicant Detail’s

Name of Permit Applicant
(person undertaking work onsite)

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

Description of Location and Activity

(including type of bulk being handled)

Permit Dates

Permit Requested For
(to be filled out by permit applicant)

DD slash MM slash YYYY
DD slash MM slash YYYY
Start Time(Required)
:
End Time(Required)
:

Permit Dates Authorised
(to be filled out by Permit Authoriser)

DD slash MM slash YYYY
DD slash MM slash YYYY
Start Time(Required)
:
End Time(Required)
:

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
Is 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 licences
Signature(Required)
Clear Signature
Date

Notification to the Vessel Master Prior to Activity Commencement (if applicable)

Prior to activation of the permit, the Permit Applicant must notify the Vessel Master who will sign below:

Signature(Required)
Clear Signature
Vessel Master

Completion Sign Off

Signature(Required)
Clear Signature
DD slash MM slash YYYY
Time
:

Port of Derby Bulks Transfer Permit

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