FORM FM0942
Application for a Petroleum Safety Zone Variation
Part 1a – Details of person making the application
Name:
Date:
Position:
Email:
Australian Address:
Phone:
On behalf of:
 (Name of titleholder and / or registered facility operator)
Being the:
Holder of title:
and / or Registered Operator of facility:
Part 1b – Details of existing petroleum safety zone(s)
NOPSEMA Reference(s):
(these references can be found in the last column of the Gazetted Notices table on the NOPSEMA
website here: http://www.nopsema.gov.au/safety/petroleum-safety-zones/gazetted-notices-listing/ )
A
Part 1c – Reason(s) for variation
Select one
or more
Type
Reasons
a
Renewal (impending expiry)
b
Change in name of facility, facility operator, or title holder
c
Change in facility operator or titleholder
d
Change to the well(s), Structure(s) and/or Equipment to be protected
☐
☐
☐
☐
Complete sections
1, 4 & 8
1, 4, 5 & 8
1, 4, 5 & 8
1 to 9 inclusive
Part 2 – Details of well(s), structure(s) and/or equipment
Equipment
Title area
Structure
Description
Well
Name
(insert rows as required
Latitude
(deg:min:sec.sec)
Longitude
(deg:min:sec.sec)
☐ ☐ ☐
☐ ☐ ☐
☐ ☐ ☐
Part 3 – Justification
(on what basis is protection being sought)
Key factors
Proximity to shipping lanes (Nm):
Proximity to commercial fisheries (Nm):
Water Depth (m):
Activities at, or in connection with the well, structure
and / or equipment:
Other factors
(narrative)
Part 4 – Timing
(when is protection being sought, must be future dates)
Commencement date:
Termination date (where applicable):
Part 5 – Scope
All vessels other than:
(vessels to be prohibited, edit as appropriate)
For example:
Vessels under the control of [ORGANISATION NAME], OR vessels under the control of the operator of the [NAME] facility, OR
vessels under the control of the holder of [TITLE ID)s)] title(s), OR these vessels:[VESSEL NAME(s)]
Part 6 – Consultation (outstanding issues)
Party consulted with:
Outstanding issue
(insert additional rows if required)
Proposed response:
Page 1 of 2
National Offshore Petroleum Safety and Environmental Management Authority
FORM FM0942
Application for a Petroleum Safety Zone Variation
Part 7 – Application checklist
Yes or N/A
1
Application is being made by a titleholder or the registered operator for the facility (or their agent)
Choose an item.
2
A consultation summary [see note 4] report is attached and referenced in Part 11 [where applicable]
Choose an item.
3
For complex safety zones a line drawing is attached and referenced in Part 11 [where applicable]
Choose an item.
4
All coordinates provided use the GDA94 Datum [where applicable]
Choose an item.
Part 8 – Sign-off
person making application
Signed:
Date:
Name:
Part 9 - Attachments
(edit as appropriate)
No.
Title
Document Id
1
[Consultation summary report, where applicable]
2
[Line drawing of complex safety zone, where applicable]
Revision
Dated
Notes:
1
Petroleum safety zones are provided for in Part 6.6 of the Offshore Petroleum and Greenhouse Gas Storage Act 2006
2
This form is intended for use by titleholders and operators of facilities applying to NOPSEMA to vary an existing petroleum safety zone.
3
Where the variation is concerned with a change to the facility name, operator or titleholder name or a change to the facility operator or titleholder the
details entered into Part 1a must reflect the changes.
4
All applicants must complete Parts 1, 4 & 8
5
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.
6
The completed form and attachments (where applicable) should be emailed to safetyzones@nopsema.gov.au.
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.
Page 2 of 2
National Offshore Petroleum Safety and Environmental Management Authority