APPLICATION FOR GAS WORK AUTHORISATION (MOTOR FUEL)

Applicant Details APPLICATION FOR GAS WORK AUTHORISATION (MOTOR FUEL) Petroleum and Gas (Production and Safety) Act and Regulation 2004 Corporation Application Details Do NOT complete if you are an Individual (Sole Trader) Corporation Name: (in full as per ACN): ACN: Applicant s Full Name: Position Title: (eg CEO, Owner etc) Sole Trader Application Details Complete only if you are an Individual (Sole Trader) Surname: First Name: Middle Name: Trading Name (if applicable) Contact Information Mobile Phone: Business Phone: Email: Address: Postal Address: Suburb: State: Postcode: Authorisation Details First application (3 years) Reapplication Change of scope Change of workshop address Adding additional workshop/s Authorisation Period Requested: 3 Years 6 years Authorisation Scope Requested: (Tick all areas which cover proposed gas work) Installing Altering Removing Servicing Repairing Testing Certifying Type of Gas Devices Requested: Automotive Engines Fixed Engines (Specific Fixed Engine Competencies to be provided) Forklifts Vessels (Marine) (Specific Marine Competencies to be provided) Type of Gas: LPG CNG LNG All Workshop Address/es to be covered under this authorisation: Workshop 1: Suburb: Postcode Workshop 2: (if applicable) Suburb: Postcode Do you wish to undertake gas work in a mobile workshop? Yes Registration Number No Do you currently hold or have an expired or cancelled Gas Motor Fuel Installers licence in QLD/another jurisdiction? Yes (detail below) No Issuing jurisdiction Licence Class Licence Number Date expired/cancelled (if not current) 1 of 9

Endorsement of Applicant I, the undersigned, declare that The information and attachments provided in this application are true and correct in every way. I certify that the workshop/s listed in this application complies with all the relevant equipment and workshop area requirements of AS2746:2008 including the requirements listed in the relevant workshop checklists of this application form. I am aware of the requirements under the Petroleum and Gas (Production and Safety) Act 2004 and Regulation relating to Gas Work Authorisations, and have read the Queensland Gas Work Licence and Gas Work Authorisation Requirements Parts 3 and 4, together with all other important notes detailed on this application form. I agree to maintain my workshop/s to the requirements listed in the attachments as a condition of my authorisation (if granted). I agree to maintain all the required equipment for servicing and certification work carried out in a mobile unit (where included), as a condition of my authorisation (if granted). I will comply with the certificate requirements of s101 and s102 of the Petroleum and Gas (Production and Safety) Regulation 2004, and agree to this being a condition of my authorisation, if granted. If I surrender my authorisation, or if my authorisation is cancelled, I agree to immediately return all unused Vehicle / Vessel Inspection Certificates and Gas Work Authorisation Certificate to the Petroleum and Gas Inspectorate. I will abide by the terms and conditions of the authorisation, if granted. Signature * CEO / Applicant (*delete one) Date: DOCUMENTS or INFORMATION REQUIRED TO BE SUBMITTED WITH THE APPLICATION Full payment by either cheque to be made payable to Department of Natural Resources and Mines, credit card payment form attached (Mastercard and Visa only are accepted). (All applications) Copies of competencies and experience for all staff undertaking gas work, or certified copy of front and back of any current or expired interstate gas licence (if applicable). (Initial applications only) Letter of application signed by the CEO or senior person responsible for providing adequate resources to ensure safety. Statement of how the authorisation holder will ensure all staff remain competent during the period of the authorisation. If not a sole trader, organisational chart showing names of all people undertaking gas work. Experience log for all staff undertaking gas work (Attachment 1); and relevant workshop checklist (Attachments 2 to 4) relevant to scope of work applied for. INFORMATION FOR APPLICANT If an application is lodged without all the required information, it will be returned without being processed. Full information is available in the relevant section of the Queensland Gas Work Licence and Gas Work Authorisation Requirements on the department s website. Emailed or faxed applications will not be processed as an original signature is required. In line with the Privacy Statement, staff are unable to discuss the application with any other party other than the licence holder/applicant. Fees effective from 1 July 2015 to 30 June 2016: Application Fee (non-refundable) per application: $69.40 plus Yearly Authorisation Fee (each year applied for) $41.55 Total payable for interim three-year authorisation $194.05 or Total payable for full six-year authorisation $318.70 Total payable for applications for Change of Scope or Change or Additional Workshop Address: $69.40 LODGEMENT OF ALL APPLICATIONS: Gas Licence and Authorisation Unit Petroleum and Gas Inspectorate Department of Natural Resources and Mines PO Box 1475, Coorparoo Qld 4151 Enquiries: Email: gaslicence@dnrm.qld.gov.au Phone: 07 3330 4249 GENERAL PRIVACY STATEMENT The Queensland Government introduced Information Standard 42 - Information Privacy to ensure that the collection, use, disclosure and storage of personal information by government agencies are lawful and appropriate. This standard also obliges agencies to tell their clients why personal information is being collected and when it is being disclosed to third parties. The Department of Natural Resources and Mines collects information on this form under the Petroleum and Gas (Production and Safety) Act 2004 (the Act) and Regulation to meet its obligations under that Act, and to facilitate and regulate the carrying out of responsible gas licensing in Queensland. Information collected on this form, whether or not it is contained in the Gas Licensing Database, may be disclosed to other Queensland Government Agencies, where such disclosure is necessary for the effective management of gas licensing in Queensland. Where information provided is commercial in confidence, it will be treated as confidential and will not be disclosed outside the agency unless the Department is legally required to do so. Further information on the department s privacy policy is available at www.dnrm.qld.gov.au. 2 of 9

Attachment 1 - Experience Log A separate Experience Log must be completed for every person who will be undertaking the scope/s of gas work relevant to the Gas Work Authorisation, if granted. Please print additional forms if required. Name: Approximate Date (last three years or last authorisation period) Detail previous gas work undertaken (eg, install, test, remove, alter, service, repair. Include make, model and gas type.) For stationary engines only Gas Device Rating (in GJ/hr) Vehicle / Vessel Inspection Certificate No (if known) Authorisation Name/Number or Employer name and contact number eg A1999 - John Smith 0433 333 333 3 of 9

Attachment 2 Workshop Checklist If more than one workshop is to be covered under this authorisation, photocopy this page and list each workshop address and relevant checklist on separate pages. Workshop Address: KEY SAFETY ISSUES AS2746 Section OK 1. Suitable equipment for providing sufficient access to vehicle underbody to ensure a safe working environment. 1 4.3 (insert or and initial) APPLICANT/HOLDER COMMENTS/DETAILS (a positive statement must be made with regard to compliance may include type/model number photo or other verifying information) INSPECTORS COMMENTS (OFFICE USE ONLY) 2. 3m area has no depressions or unventilated pits etc. Note: use of service pit is not recommended. 4.4(c) and (d) 3. Adequate ventilation system 4.5 Describe ventilation and how it meets requirements. 4. Increased hazard requirements Appropriate signage eg: No Smoking Flammable Gas 4.6 5. Storage of cylinders complies with AS1596 4.12 6. Describe what provision you have for loading/unloading fuel App B, C gas tanks 2 Note: s4.9 stipulates when fuel loading must be undertaken (by one of three means in Appendix C) if no unloading equipment, how is fuel unloading to be undertaken? 7. Inert gas pressure testing equipment suitable to 3.3 Mpa App B 8. Vacuum/pressure gauges with pressure ranges of 0-200 Kpa App B 1 Note: Service pits are not recommended. Where they must be used eg for heavy vehicles, adequate ventilation must be provided inside the pit. This will need to be demonstrated at inspection. 2 Where the applicant/holder can positively demonstrate that tank loading or unloading is not carried out, this requirement may be waived by a Petroleum and Gas Inspector. 4 of 9

Attachment 2 Workshop checklist, continued KEY SAFETY ISSUES AS2746 Section OK 9. Electronic combustible gas detector capable of a minimum of 40 parts per million 3 App B (insert or and initial) APPLICANT/HOLDER COMMENTS/DETAILS (a positive statement must be made with regard to compliance may include type/model number photo or other verifying information) INSPECTORS COMMENTS (OFFICE USE ONLY) 10. Four gas type exhaust gas analyser 4 App B 11. Current copy of AS/NZ1425 5 App B 12. Current copy of AS4983 (for forklifts and stationary engines) 6 13. Appropriate fire extinguisher (dry powder for a minimum fire rating 40B (>2.7kg). 14. Flaring tools / pipe cutter App B OFFICE USE ONLY 1. All Items 1-14 were physically inspected and found to comply Yes/No 2. Applicant has been advised of certification requirements for installations, inspections and repairs. Yes/No 3. Applicant has been advised of the need to have systems in place for qualification and training records to be maintained Yes/No 4. Ratio of fully competent persons to non-fully competent persons is appropriate (recommended no more than 1 fully competent : 2 non fully competent) Yes/No RECOMMENDATION: GPO Number: Workshop Accepted YES NO Petroleum & Gas Inspector Date: 3 Required by AS2746:2008 although App C in AS1425 outlines a variety of leak detection methods for LP Gas. 4 See Petroleum and Gas Small Automotive Workshops Compliance Policy (1-3 workers) 5 AS/NZ 1425:2007 LP Gas fuel systems for vehicle engines. 6 AS 4983:2010 Fuel gas systems for forklifts and industrial engines is required if the requested type of gas device includes forklifts or fixed engines. 5 of 9

Attachment 3 Equipment Checklist for Mobile Workshop Registration Number: KEY SAFETY ISSUES AS2746 Section 1. Describe what provision you have for loading/unloading fuel gas tanks 1. App B, C Note: s4.9 stipulates when fuel loading must be undertaken (by one of three means in Appendix C) if no unloading equipment how is fuel unloading to be undertaken? 2. Supply of inert gas pressure, regulator and hoses (purging and testing), App B suitable for 3.3 MPa test of LP gas container sub-assembly. 3. Vacuum/pressure gauges with pressure ranges of 0-200 Kpa App B OK (insert or and initial) APPLICANT/HOLDER COMMENTS/DETAILS (a positive statement must be made regarding compliance may include type/model number photo or other verifying information) INSPECTORS COMMENTS (OFFICE USE ONLY) 4. Electronic combustible gas detector capable of a minimum of 40 parts App B per million 2 5. Four gas type exhaust gas analyser 3 App B 6. Current copy of AS/NZ1425 4 App B 7. Current copy of AS4983 (for forklifts) 5 App B 8. Appropriate fire extinguisher (dry powder for a minimum fire rating 40B (>2.7kg). 9. Flaring tools / pipe cutter App B 10. Cooling system leak test equipment App B OFFICE USE ONLY 1. All Items 1-10 were physically inspected and found to comply. Yes/No 2. Applicant has been advised of certification requirements for inspections and repairs. Yes/No 3. Applicant has been advised of the need to have systems in place for qualification and training records to be maintained. Yes/No 4. Ratio of fully competent persons to non-fully competent persons is appropriate (recommended no more than 1 fully competent : 2 non fully competent) Yes/No RECOMMENDATION: GPO Number: Equipment Accepted YES NO Petroleum & Gas Inspector Date: 1 Where the applicant/holder can positively demonstrate that tank loading or unloading is not carried out, this requirement may be waived by a Petroleum and Gas Inspector. 2 Required by AS2746:2008 although App C in AS1425 outlines a variety of leak detection methods for LP Gas. 3 See Petroleum and Gas Small Automotive Workshops Compliance Policy (1-3 workers) 4 AS/NZ 1425:2007 LP Gas fuel systems for vehicle engines. 5 AS 4983:2010 Fuel gas systems for forklifts and industrial engines is required if the requested type of gas device includes forklifts or fixed engines. 6 of 9

Attachment 4 Equipment Checklist for Certification Only This checklist is to enable holders of a gas work authorisation (motor fuel) to certify, by verifying that they meet the requirements of the Petroleum and Gas (Production and Safety) Act 2004 with respect to the equipment requirements of AS 1425 and AS 4983 respectively, and AS2739 for CNG certification. KEY SAFETY ISSUES OK insert or and initial APPLICANTS /HOLDER COMMENTS/DETAILS (a positive statement must be made with regard to compliance may include type/model number photo or other verifying information) INSPECTORS COMMENTS (OFFICE USE ONLY) 1. Current copy of Australian Standards AS 1425 1 and AS 2739 2. Current copy of Australian Standards AS 4983 2 3. Electronic gas detector capable of a minimum of 40 parts per million 4. Leak detection solution 5. In test Fire extinguisher (dry powder for a minimum fire rating 40B (>2.7kg). 6. Set of vehicle ramps or access to a set of ramps or hoist 7. Electronic circuit tester or multi meter pen 8. Inspection kit, comprising Tape measure Torch Spanners Screwdrivers Power drill 9. Copy of a LPG - SDS (safety data sheet) OFFICE USE ONLY All Items 1-9 were physically inspected and found to comply Applicant has been advised of certification requirements for installations, inspections. Applicant has been advised of the need to have systems in place for qualification and training records to be maintained Ratio of fully competent persons to non-fully competent persons is appropriate (recommended no more than 1 fully competent : 2 non fully competent) RECOMMENDATION: Workshop Accepted YES NO Petroleum & Gas Inspector Date: GPO Number: Yes/No Yes/No Yes/No Yes/No 1 AS/NZ 1425:2007 LP Gas fuel systems for vehicle engines. 2 AS 4983:2010 Fuel gas systems for forklifts and industrial engines is required if the requested type of gas device includes forklifts or fixed engines. Approved Form PGA728A Version Number 16 Effective from 1 July 2015 7 of 9

PAYMENT: Application Fee: $ RECEIPT NUMBER: Authorisation Fee: $ OFFICIAL USE ONLY DECISION: Approved Rejected Scope of Work: Installing Altering Removing Repairing Servicing Testing Certifying Device: Automotive Engines Forklifts Stationary Engines up to GJ/hour Vessels (Marine) Gas LPG CNG LNG Authorised Workshop Address/es: Mobile Workshop: Yes No Registration No: Delegate for the Chief Inspector Petroleum and Gas Name: Date: / / Authorisation Number: A Expiry Date: / / Approved Form PGA728AV Version Number 16 Effective 1 July 2015 8 of 9

Credit Card Payment Request PAYEE DETAILS: Full Name: Address: State: Postcode: Telephone: ( ) Fax: ( ) DESCRIPTION (please tick appropriate boxes) Gas Work Authorisation fees (3 years) $194.05 Gas Work Authorisation fees (6 years) $318.70 TOTAL $ PAYMENT DETAILS Payment Type Mastercard Visa (Please Tick) Amount of Payment $ Expiry Date.. /.. Card Number Cardholder s Name.... Phone No...... Cardholders Signature.... Date..... /..../. Privacy Notice The Department of Natural Resources and Mines is collecting the information on this form to charge your credit card for one of the purposes identified in the description section of this form. Only authorised departmental officers have access to this information and your information may be disclosed to your nominated financial institution for the purposes of processing this transaction. Your personal information will not be disclosed to any other third party without your consent, unless required to do so by law or for the purposes of the Information Privacy Act 2009. Approved Form PGA728AV Version Number 16 Effective 1 July 2015 9 of 9