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N 04800 fm0942 application for a petroleum safety zone renewal

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					                                                                                                                                               FORM FM0942
                                                                         Application for Renewal of a Petroleum Safety Zone

 Part 1 – Details of person making the application
 Name:                                                                                                              Date:

 Position:                                                                                                          Email:

 Australian Address:                                                                                                Phone:

 On behalf of:                                                                                                       (Name of titleholder or registered facility operator)

 Being the:                 Holder of title:                                     or Registered Operator of facility:

 Part 2 – Details of well(s), Structure(s) and/or Equipment                                                                          (what is being protected, use part A, B, or C)

 Part 2A - Details of petroleum safety zone notice gazettal by NOPSEMA                                                                                       (Post 1 January 2012)

 NOPSEMA Reference:               A                        (this reference can be found on the letter from NOPSEMA advising of a successful application)

 OR Part 2B - Details of petroleum safety zone notice gazettal by a Designated Authority                                                                      (Pre 1 January 2012)

 Date of gazettal:                                             Which Gazette? (e.g. WA, Vic etc)                                       Gazette No:

 OR Part 2C - Details of well(s), Structure(s) and/or Equipment t                                                            (thought to be protected by a petroleum safety zone)

 Name                          Description                                                                          Title area         Latitude                Longitude
                                                                                                                                       (deg:min:sec.sec)       (deg:min:sec.sec)



                                                                                                        Equipment
                                                                                            Structure
                                                                                     Well




 Part 3 – Timing                                                                                                                                (when is protection being sought)

 Commencement date:                                                       Termination date (where applicable):

 Part 4 – Scope                                                                                                                     (vessels to be prohibited, edit as appropriate)

 All vessels other than:       vessels under the control of the applicant

                               vessels under the control of the operator of the [NAME] facility OR holder of [title] title(s)

                               these vessels: [provide names of vessels excluded from prohibition]

 Part 5 – Consultation (outstanding issues)                                                                                                    (insert additional rows if required)

 Party consulted with:                         Outstanding issue                                                      Proposed response:




 Part 6 – Application Checklist                                                                                                                                       Yes 
 1         Submission is being made by a titleholder or the registered operator for the facility (or their agent)

 2         A consultation summary [see note 3] report is attached and referenced in Part 8

 3         For complex safety zones (multiple items) [see note 2] a line drawing is attached and referenced in Part 8

 4         All coordinates provided use the GDA94 Datum

 Part 7 – Sign-off                                                                                                                                     person making application

 Signed:                                                                                                            Date:


Revision: 1                                                                   Page 1 of 2                                                              Reference: N-04800-FM0942
Revision Date: 18 March 2014                                                                                                                                 Objective ID: A200694
                                           National Offshore Petroleum Safety and Environmental Management Authority
                                                                                                                                                FORM FM0942
                                                                                    Application for Renewal of a Petroleum Safety Zone
 Name:

 Part 8 - Attachments                                                                                                                                         (edit as appropriate)

 No.             Title                                                                                                        Document Id          Revision        Dated

 1               [Consultation summary report, where applicable]
 2               [Line drawing of complex safety zone, where applicable]


 Instructions for use:
 1         This form is intended for use by titleholders and operators of facilities applying to NOPSEMA for the renewal of a soon to expire / re-establishment or a
           recently expired petroleum safety zone.
 2         Applicants should complete Parts 1 to 5 and use Part 6 as a checklist to ensure all items have been address/included as part of the application before
           signing Part 7. Attachments should be clearly listed in Part 8.
 3         The consultation summary report should address any changes to the:
           (a)                 parties consulted with, and;
           (b)                 assessment by the applicant of the legitimacy of any objection or claim of adverse impact, and;
           (c)                 statement of the manner (if any) in which the applicant has responded or proposes to respond to each objection or claim;
           since the application for the establishment of the petroleum safety zone.
 4         The completed form, consultation summary report and, line diagram of the petroleum safety zone, where applicable, should be emailed to
           safetyzones@nopsema.gov.au.

 Notes:
 1         Petroleum safety zones are provided for in Part 6.6 of the Offshore Petroleum and Greenhouse Gas Storage Act 2006
 2         From NOPSEMA Policy N-04800-0916:
           Where an applicant is requesting the establishment of a petroleum safety zone that encompasses a combination of one or more wells, structures or items
           of equipment the application shall include:
           (1)           a black and white line drawing of the proposed safety zone that includes:
                         (a)        a graphical representation of boundaries of the proposed petroleum safety zone including latitudes and longitudes sufficient to clearly
                                    delineate the area;
                         (b)        graphical representations of items of significant infrastructure including by not limited to: wells, production facilities, moorings, flow-lines
                                    and manifolds.
           (2)           a tabulation of the latitude and longitude of all wells, facilities (structures and vessels), manifolds or other significant items of subsurface
                         infrastructure.
 3         From NOPSEMA Policy N-04800-0916:
           (1)           An application for establishment of petroleum safety zone must include a report that describes consultation the applicant has undertaken with:
                         (a)        relevant Commonwealth and State/NT agencies; and
                         (b)        any users of the ocean commons (person or organisation) likely to be especially affected by the establishment of the petroleum safety
                                    zone.
           (2)           The report on consultation undertaken must include:
                         (a)        a summary of each response made by an agency, person or organisation that has been consulted by the applicant;
                         (b)        an assessment by the applicant of the legitimacy of any objection or claim of adverse impact; and
                         (c)        a statement of the manner (if any) in which the applicant has responded or proposes to respond to each objection or claim.

Privacy Notice
NOPSEMA collects your personal information for the purposes of administering the Offshore Petroleum and Greenhouse Gas Storage Act 2006 and associated
regulations.
NOPSEMA will not use or disclose your personal information for any other purpose without your consent, unless it is required or authorised by law, or relates to
NOPSEMA’s enforcement activities. Your personal information may be disclosed to the following organisations, entities or individuals:
                individuals who make a request under the Freedom of Information Act 1982
                the Australian National Audit Office and other privately-appointed auditors
                other law enforcement bodies (for example, the police or the Coroner)
                NOPSEMA’s legal advisors.
NOPSEMA may occasionally be required to disclose information to overseas recipients in order to discharge its functions or exercise its powers, or to perform its
necessary business activities.
Information about how you can access, or seek correction to, your personal information is contained in NOPSEMA’s APP Privacy Policy at
www.nopsema.gov.au/privacy. If you have an enquiry or a complaint about your privacy, please contact NOPSEMA’s Privacy Contact Officer on 08 6188 8700 or by
email at privacy@nopsema.gov.au.

Revision: 1                                                                              Page 2 of 2                                                   Reference: N-04800-FM0942
Revision Date: 18 March 2014                                                                                                                                 Objective ID: A200694
                                                     National Offshore Petroleum Safety and Environmental Management Authority

				
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