F2.20a Application for Traffic Management

The Applicant shall complete Sections 1 and 2, sign Section 3.1 and submit to the MWPA for approval.

MWPA Use Only / Permit No. / JSEA No.
Section 1: GENERAL
Applicant company: / Email address:
Company Representative: / Representative contact no.
Permit Valid
From: / Date: / To: / Date:
Section 2: WORK DETAILS, PRECUATIONS AND CONDITIONS
Section 2.1: Description of Works
Location of Works
Description Of Works
Section 2.2: Purpose of Traffic Management
Section 2.3: Impact on Port Facilities
Which Port roads will be affected?
Connell Road (Northern end) / Connell Road (Southern end)
Gillam Road / Reg Clarke Road
Ian Bogle Road (west outside secure zone) / Ian Bogle Road (inside secure zone)
Ian Bogle Road (east outside secure zone) / Lemmon Road
Graham Road
What impact will there be on normal road rules (e.g. change to speed, reduce lane width, one way)?
Section 2.4: Vehicle Type and Movement
Vehicles involved in operations
No. / Vehicle type / No. / Vehicle type
Light vehicles / Trucks – Semi
Trucks – B double / Trucks – Triples
Other (detail including truck length)
Queuing location – If operation involves trucks, where will they queue (not on berths, Port roads, or car park at Fishing Boat Harbour)
Bullring (off John Wilcock Link) / Other (describe)
Section 2.5: Pedestrian Interface
What pedestrians will be affected? How will you ensure their safety?
Section 2.6: Key Risks
What are the key risks affecting your workers, other workers and other Port operations?
Risk (also consider other operations) / Traffic Management measures to manage the risk
Drawing attached. A drawing showing location of signage, witches hats, barriers, route directions, etc. must be attached to this permit. Road names and traffic direction must be clear. /
Section 3: MWPA RECEIPT, PERMIT APPROVAL AND ACCEPTANCE, PROCESSED

By applying for this permit, the Applicant makes the following warranties, undertakings and acknowledgements:

·  The Applicant warrants that it understands the nature of the work permitted by the permit and risks associated with it, has sufficient competence to carry out the work and accepts responsibility (including occupational health and safety responsibility) for the work.

·  The Applicant undertakes to notify MWPA as soon as possible after it identifies any issue which would prevent the work from being carried out safely, and to liaise with MWPA to allow the work to be carried out safely.

·  The Applicant acknowledges that the issuing of this permit does not constitute approval by the MWPA of the work or occupational health and safety procedures in relation to the carrying out of the work.

Section 3.1: Applicant’s Authorised Representative
(Name) / (Signature) / (Date)
(Title)

Should you have any queries, please contact MWPA Wharf Supervisor on (08) 9964 0510

Completed permits should be emailed to

Section 3.2: MWPA Approval
OHS Officer / Name: / Signature: / Date:
Wharf Supervisor / Name: / Signature: / Date:
Rejected – Revise and Resubmit / Approved
Commentary and additional conditions
Section 3.3: Acceptance of Conditions/Requirements (If Required)
By signing this document, the undersigned has read, understood and accepted the terms and conditions of this application and declares that all information is true and accurate.
Applicant name / Signature / Date:
APPROVAL ISSUED ONLY WHEN SIGNED BELOW, BY AUTHORISED MWPA REPRESENTATIVE
AND PROCESSED BY THE WHARF SUPERVISOR
Section 3.4: Permit Processed by
(Name) / (Signature) / (Date)
(Title)
Section 3.5: Notifications
Notifications: / Applicant / Security Gate House / Other Relevant Party
Permit / Included in Daily Works
Section 4: PERMIT CLOSURE
Completion advised and site checked / Date:
Permit Closed by / Date:
Update Database / Update Permit Board
Section 5: MWPA TERMS AND CONDITIONS
1. / To ensure timely approval, this application must be lodged a minimum of 2 working days (48 hours) prior to commencement of the work.
2. / The Traffic Management Plan must be discussed with all relevant parties at a pre-start meeting. A Truck Coordinator/s must be appointed. This person is responsible for all traffic movements, traffic control and trucking operations and will be contacted by MWPA if there are any concerns, including failure to wear correct personal protective equipment (PPE) inside the Port.
3. / You are responsible for ensuring all trucking companies are informed of PPE requirements if moving outside vehicle for any period of time (long sleeved shirt, long pants with high-visibility stripes, helmet (hi-visibility stripes if working at night), safety glasses, safety footwear).
4. / No work can commence until a signed approval from MWPA has been received (in hard copy or via email) and any additional conditions/requirements have been accepted.
5. / Any safety or environmental incidents, or damage, during works must be reported to the MWPA immediately. After hours, please call (08) 9964 0510. With regard to such incidents, you are responsible to make good the site and any other affected areas to the satisfaction of the MWPA.
6. / All personnel accessing MWPA sites are required to have completed a MWPA induction. Within the secure zone, individuals are also required to carry their own Maritime Security identification Card (MSIC) at all times. A visitor’s pass may be obtained but all visitors must be escorted at all times by a holder of a current MSIC.
7. / Any failure to gain approval for work, or failure to comply with MWPAs Requirements of Contractors document or Permit Procedures may result in a penalty or permission to enter MWPA sites being withdrawn until al MWPA requirements are met.
8. / This permit to be held on site at all times during the works.
Should you have any queries, please contact MWPA Duty Wharf Supervisor on (08) 9964 0510.
Completed permits should be emailed to

Custodian: OHS Officer

Uncontrolled when printed or in hard copy

F2.20a – V4 – 13/6/2016 Page 2 of 4

F2.20a Application for Traffic Management

Uncontrolled when printed or in hard copy

F2.20a – V4 – 13/6/2016 Page 2 of 4