APPLICATION FOR AUTHORISATION OF AN EXPLOSIVE OR UNAUTHORISED EXPLOSIVE APPROVAL

Transcription

1 DAGEROUS GOODS ACT 1985 DAGEROUS GOODS (EXPLOSIVES) REGULATIOS 2011 WORKSAFE VICTORIA August 2011 APPLICATIO FOR AUTHORISATIO OF A EXPLOSIVE OR UAUTHORISED EXPLOSIVE APPROVAL Office use only checklist (please circle) Please refer to General Information and Instructions at the end of this form for guidance on completing and submitting this application. 1. Application Type (tick application type) I wish to apply for: Authorisation of an Explosive Interim Unauthorised Explosive Approval Temporary Unauthorised Explosive Approval Amendment to Existing Authorisation o. Application type 2. Applicant Details a. Complete this Part if the Applicant is a atural Person Family ame Given ames Is Part 2 Trading As (if applicable) Residential Address Postal Address Telephone (BH) Telephone (AH) Mobile TRIM o. _ Facsimile Date of Birth (applicant must be at least 18 years of age) / / b. Complete this Part if the Applicant is not a atural Person Full Legal ame of Organisation Trading As Registered Address Postal Address Contact Person ame Telephone Facsimile Page 1 of 5

2 3. Explosive Type and Classification ame of Explosive (as you wish it to appear on the Authorisation) Part 3 Proper Shipping ame Classification Code U o Type of Explosive (eg detonating cord, detonator, blasting explosive, flare, safety fuse, etc) Article Substance Primary Use (eg blasting, pyrotechnics, theatrical effects, etc) ame of Manufacturer Address of Manufacturer Supporting Documentation Attached Proof of Classification by Analogy Testing Attached es Technical Information (eg Technical Bulletins, Data Sheets, Drawings, Photos) Attached es Material Safety Data Sheets Attached es OTE: ou must provide documentation from a recognised Competent Authority which classifies the explosive and includes, where required, results of classification tests conducted in accordance with U criteria. Has the explosive been authorised in any other jurisdiction? es o If yes, specify which jurisdiction(s) ACT es SW es T es QLD es SA es TAS es WA es Department of Defence es Overseas es (specify) o OTE: Copies of authorisations from other jurisdictions to be provided with application. 4. Explosives Formulation Chemical Composition (Correct Chemical ames) Content and Tolerances (% w/w) Part 4 OTE: For explosive articles, the chemical composition of the explosive substance (in the explosive article) is required with the content expressed as a percentage of the explosive substance (not as a percentage of the article). For explosive articles et Explosive Quantity (EQ) per article Page 2 of 5

3 5. Explosives Characteristics Is Part 5 ote ou must provide characteristics appropriate to the type of explosive, eg: High explosives: sensitivity, density, VOD (velocity of detonation) (confined / unconfined), energy, stability Detonating cords: VOD, tensile strength Safety Fuse: burning rate, burning rate tolerance, lateral ignition, water resistance Detonators: delay numbers, delay period (ms) Propellants: thickness, colour, grain shape, perforation, density, burning rate, stability test results Boosters: sensitivity, VOD Fireworks: effects, duration, burst spread, lining and bursting charges, height of effect Other Explosives effect, physical form (powder, pellets, etc) and properties 6. Construction of Explosive Articles Part 6 Outer Covering Labelling on Individual s (include photographs/dummy samples where possible) 7. Packaging U Packaging Approval o Packing Instruction o Inner Intermediate Outer Part 7 Contents Dimensions Weight OTE: Contents: umber of articles/weight of substance per inner, intermediate and outer packages. Page 3 of 5

4 8. Labelling Outer Package Is Part 8 Size of Print Details Proper Shipping ame Lot and Batch umber Authorised ame ame and Australian Address U umber Date of Manufacture Class Label Package Approval o Subsidiary Label Word Explosive Other Markings Inner Package Details Authorised ame Class Label Subsidiary Label ame and Australian Address Other Markings 9. Safety Shelf Life Potential Hazards ature of Deterioration Special Precautions in Use Any other Relevant Information Is Part Unauthorised Explosive Approval Details (For Interim Unauthorised Explosive Approval and Temporary Unauthorised Explosive Approval Only) Is Part 10 Reason/s for requesting this approval including the period of time required. 11. Declaration I, declare that all the information contained in and accompanying this application is, to the best of my knowledge, true. I understand that this is an offence under the Dangerous Goods Act 1985 to provide false or misleading information. Signature Date D D M M Page 4 of 5

5 12. Payment Options The fee to test or examine explosives for the registration of an explosive is $ The fee to amend an existing authorisation is $ There is no fee for an unauthorised explosives approval. (o GST applies to this application) Paying by mail I wish to pay by Cheque OR Money order Make cheque/money order payable to WorkSafe Victoria. Paying by credit I wish to pay by credit card card Please charge payment of $ to my MasterCard Visa Fee paid? Receipt o? Receipt date? Card o. Expiry Date / / Cardholder ame Signature 13. Collection of Personal Information Personal and/or health information collected by WorkSafe in connection with this application will be used for the purpose of assessing this and any associated applications. The information collected may also be used in the administration and enforcement of legislation administered by WorkSafe, including the Occupational Health and Safety Act 2004 and the Dangerous Goods Act 1985, the administration and evaluation of WorkSafe s programs generally and for law enforcement functions and legal proceedings. WorkSafe may disclose personal and/or health information for public health and safety purposes. It may disclose that information to other government agencies, including emergency services, law enforcement and security agencies, including Victoria Police. WorkSafe may also disclose personal and/or health information to its contractors and agents, to a court or tribunal, to other regulatory agencies and to any person authorised to whom it relates, or by law, to obtain it. WorkSafe may disclose a person s licence status to employers, prospective employers or members of the public who wish to check this status. Collection of your personal and/or health information may be required by the Occupational Health and Safety Act 2004 or Dangerous Goods Act 1985 and associated Regulations. If you do not provide any or all of the information your application may not be accepted or processed. ou may access your personal information held by WorkSafe by contacting the Freedom of Information and Privacy Team. WorkSafe s Privacy Policy is available at worksafe.vic.gov.au. Officer signature Audited by Date audited / / 14. Contact Details Submit your completed application form and all supporting documentation to: WorkSafe Victoria Telephone (03) Dangerous Goods Branch Facsimile (03) GPO Box dangerousgoodsunit@worksafe.vic.gov.au Melbourne Vic OTE: Unsigned or incomplete applications or applications not accompanied by the required documentation may not be processed. Further information relevant to this application is available on our website at worksafe.vic.gov.au. WorkSafe Victoria is a trading name of the Victorian WorkCover Authority FOR695/03/08.11 Page 5 of 5