Permit No. (Office use only) Mines ABN 24 830 236 406 Notice of completion of seismic survey or scientific or technical survey Petroleum and Gas (Production and Safety) Regulation 2004 Petroleum Regulation 2004 Geothermal Energy Regulation 2012 Form Number PA-22A Version Number 4 Further information and copies of forms can be obtained from the Department of Natural Resource and Mines or GUIDE FOR APPLICANTS from the internet: www.mines.industry.qld.gov.au. Note: Pursuant to section 813 of the Petroleum and Gas (Production and Safety) Act 2004 and section 332 of the Geothermal Energy Act 2010, a document containing information that is false or misleading may attract a maximum penalty of 500 penalty units. The original of this should Please print clearly in ink and use block letters. If there is insufficient space, use attachments. be forwarded to the 1. Indicate the type and number of the permit the survey was conducted within Department within 10 or, for a data acquisition authority, the petroleum tenure to which the data business days after the acquisition authority relates: completion date of the survey. A copy of this 1.0 Tenure type: notice must be served on each landowner and occupier at least 10 1.1 Tenure number: business days after the completion date of the survey. Principal holder 1.2 name: Question 1 For a data acquisition authority, detail the petroleum tenure type 2. Survey details: and number to which the data Type of survey: acquisition authority relates. 2.1 seismic survey Question 1.2 Indicate the name and details of the principal holder, in whose If seismic survey 2D or 2.2 petroleum authority the survey 3D: was conducted. Indicate the name of the operator, previously nominated by the 2.3 Operator name: principal holder of the petroleum authority in which the survey was conducted. Identifying name or 2.4 code for the survey: Question 2.1 For example, seismic, geophysical, geochemical, geotechnical, ariel etc. Actual date of 2.5 commencement: Question 2.4 A survey is completed as soon as all the raw data for the Line Spacing 2.6 survey has been recorded or (magnetics) recovered. Station density 2.7 (gravity): Area (km sq) or line km 2.8 (where applicable) Energy Source 2.9 (where applicable): Magnetometer (where 2.10 applicable): Gravity Meter (where 2.11 applicable): 2 GUIDE FOR APPLICANTS 3. Local tenure contact details 3.1 Provide the contact name and details of the tenure holder or an authorised Question 3. person who may be contacted to discuss any matters stated in this notice. Enter the name, address and Full name contact details for the authorised person who is the contact in respect to the notice. Company The contact person may be either a holder of the tenure or a person authorised to act on behalf of the holder. Address The nominated contact person will be required to discuss any matters stated in the notice if contacted by the landowner and occupier of the land subject to the notice. Suburb Notes for landowner and occupier: State Post code If you have any questions relating to the contents of this notice, please contact the Phone number Fax number person listed in Question 3. Mobile number Email address 4. Signature of holder or authorised person: By signing you confirm that the relevant sections of the Petroleum and Gas (Production and Safety) Act 2004, Petroleum Act 1923 and the Geothermal Energy Act 2010 and their associated regulations will be complied with, and that the information contained within this notification is true to the best of my knowledge. Attachment A Map Tick Question 4. The signature of a relevant This map must clearly show: technically competent officer is Location of the area to be surveyed required. Any existing permits Note: To submit forms Location of any other known wells, water bores, previous surveys and electronically, email public utilities. email@example.com Attachment B Performa .gov.au Additional Requirements Additional requirements A copy of this notice must be A copy of this notice must be served on each landowner and occupier of the land 10 business day provided to each landowner and before you enter to undertake activities. occupier. Tick the box to verify that this requirement has been Tick met. I acknowledge that a copy of this notice will be served on each landowner and occupier of the land 10 business days before entry. Disclaimer The Queensland Government Department is collecting information provided on this form for the purposes of assessing the suitability of your notice of completion of seismic survey or scientific or technical survey and maintain the public searchable register under the Petroleum and Gas (Production and Safety) Act 2004 (‘P&G Act’), Petroleum and Gas (Production and Safety) Regulation (P&G Reg’), Petroleum Act 1923 (‘PA1923’) and Petroleum Regulations 2004 (‘the Reg’), the Geothermal Energy Act 2010 (GEA) and the Geothermal Energy Regulation 2012 (GEA Reg). This information is authorised by sections 34 of the P&G Reg and 565 of the P&G Act, section 19 of the Reg and 80B of the PA1923, section 273 of the GEA and section 11 of the GEA Reg. Some or all of this information may be provided to other agencies of the Queensland Government for the issuing of an environmental authority, to make register searches, extracts or copies under section 566 of the P&G Act, 80CA of the PA1923 and 275 of the GEA. Your personal information will not otherwise be disclosed to any other third party without your consent, unless authorised or required by law.
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