Asbestos Removal Or Associated Work: Permit for Work Approval Page 1 of 2

Where the removal of Asbestos from a Business Unit Site is required, the Code of Practice for the Safe Removal of asbestos [NOHSC: 2002 (2005)] and all local legal requirements must be met.
NOTE:All YES responses on this form, require supporting documentation that should be attached to this
Request for Approval.
SITE AND WORK DETAILS
Date / Job #
Site Address / State
Expected Start Date / Expected Finish Date
Property Number
Business Unit Manager
Scope of Details of Work:
TYPE OF ASBESTOS
Friable / Specific Friable / Non-Friable / Specific Non-Friable
Specify Type
Area of Asbestos to be removed / < 10m2 / > 10m2
Expected amount of time to undertake work / < 1 hour / > 1 hour
Asbestos Removal is: / Indoors / Outdoors
Floor plan of area showing asbestos attached / Yes / No
Asbestos Analysis Reports / Yes / No
Material to be removed is in the Hazardous Material Register / Yes / No
Supply Details from HMR:
Any IT infrastructure or telecommunications effected / Yes / No
Any Security issues or work required / Yes / No
The work constitutes a risk to others / Yes / No
Employee Consultation/Induction has been carried out / Yes / No
AGENT DETAILS
Agent Company (as shown on Licence)
Address / State
Principal Agent
Phone
Asbestos Removal Licence Number / State of Issue
Issue Date / Expiry Date
Type of Licence or Class
Has the Company or any personnel involved with the Company ever had an application, licence or approval to remove asbestos refused, suspended, cancelled or revoked? / Yes / No
INSURANCE TYPES
Current Workers Compensation Insurances / Yes / No
Current Public/Product Liability Insurance (Value $____M) / Yes / No
Current Asbestos Removal Insurance (Policy #______, $______) / Yes / No
Current Professional or All Contractor Risk Insurance / Yes / No
Current Certified Safety Management System to AS4801 / Yes / No
AGENT PERSONNEL DETAILS AND TRAINING
Names / Type of Certificate / Certificate Number / Date
Nominated Supervisor assigned for Site
Nominated Personnel
Nominated Personnel
Nominated Personnel
Nominated Personnel
INFORMATION / DETAILS
Control Plan Available / Yes / No
Safe Work Methods / JSA, LSEA work safety plan available / Yes / No
Equipment [HEPA vacuum/Neg Air unit/Decon unit (filters)/ Respirators] Maintenance/Check Log kept and available / Yes / No
Local waste disposal requirements identified / Yes / No
Notification to local authority / Yes / No
Air Conditioning isolation has been approved / Yes / No
Work is to be carried out during normal Banking hours / Yes / No
Detail Dates and Work hours
Other Items (Comments) / Yes / No
MONITORING DETAILS
Is Para Occupational Air Monitoring required (attach copy of Risk Assessment) / Yes / No
Monitoring Company
Address / State
Phone
Professional / Asbestos Insurance (Policy # ______, $______) / Yes / No
NATA Certified (Certificate # ______) / Yes / No
Site Monitoring Plan / Yes / No
Other Comments / Special Conditions:
Approval to Issue Permit to Work
Asbestos Control Manager:
Date:
Permit Number:
Permit Issued By:
POST REMOVAL INFORMATION / DETAIL
Site Register has been updated / N/A / Yes / No
Pre and post Air Monitoring reports (NATA) / N/A / Yes / No
Clearance Certificate / N/A / Yes / No
Asbestos Disposal Docket (# ______) / N/A / Yes / No
Manager advised site is clear / N/A / Yes / No
Permit to Work Closed (# ______) / N/A / Yes / No
Other Comments / Special Conditions:
Project Closed
Asbestos Control Manager:
Date:
A copy of this document along with any MSDS and Safe Work Methods must be forwarded on completion to:
Gecko MMS Pty Limited
PO Box 878
YEPPOON QLD 4703
Fax: 07 4939 2473 or Email:

Asbestos Removal or Associated Work: Permit for Work Approval Page 1 of 2