Pursuant to MinesSafety and Inspection Act 1994 [s. 47(3)] and MinesSafety and Inspection Regulations 1995 [rr. 3.3, 3.4] 100 Plain Street EAST PERTH WA 6004 Tel: (08) 9358 8001 Option 3 www.dmirs.wa.gov.au SRSmanager@dmirs.wa.gov.au

Exploration operation notification

Region

Send the completed form to the senior inspector of mines for the region where the exploration will take place. Please tick applicable inspectorate box. View Regional Inspectorate boundaries for Mining and Regional Inspectorate boundaries by Shire on webpage.

Operation details
Exploration manager / Syndicate Leader
Exploration company / Syndicate Name
Is this for a syndicate as per Mines Safety and Inspection Act 1994 – As per s.46A(2) and s.47(5)?
ABN/ACN
Address	Postcode
Telephone	Fax
Email
Person Responsible for Management of Exploration Activity
Telephone
Local Government Authority
Eastings Coordinate	Northing Coordinate	MGA Zone
Tenement numbers where operations will take place
Are you the Tenement Owner?	(If No, please provide evidence of permission from Tenement Owner)
Notification for a period of	Date of notification
Proposed commencement date	Click or tap to enter a date.
Proposed conclusion date	Click or tap to enter a date.
Nature and scope of proposed activities
Are the proposed operations earth-disturbing operations?
Earth disturbing operations (please complete this section if selected ‘Yes’ above.)
Costeaning
Line metres
Average depth
Tonnes excavated
Type of equipment
Drilling
Type(s) e.g. RAB, RC
Number of holes
Earthworks
Type of equipment
Other operations (non-earth disturbing operations) (please complete this section if selected ‘No’ above.)
Specify (e.g. field mapping)
Note: Where the schedule of work is extensive, details should be attached to this form.
General Safety
Scope of Operations
Will there be a night shift?
Maximum number of people
During the course of this notification, exploration operations occur in the following types of terrain Operations at night or in more complex terrain are inherently more risky.
Access to site
Include any special instructions on how to find your operations i.e. if existing tracks
Safety Considerations
Radiation
Fibrous
First Aid