Notice to export explosives or security sensitive ammonium nitrate (SSAN) into Western Australia

Dangerous Goods Safety Act 2004
Dangerous Goods Safety (Explosives) Regulations 2007
Dangerous Goods Safety (Security Sensitive Ammonium Nitrate) Regulations 2007
ABN: 69 410 335 356

Requirements for this notice

·  This notice is to be used for exports of explosives or SSAN.
·  Separate notices are to be lodged if explosives and SSSAN are included in the same shipment.
·  The person exporting the explosives or SSAN must hold a current explosives or SRS import/export licence.
·  This notice must be lodged by the licence holder with Resources Safety at least 7 days prior to the date of expected departure.
·  The licence holder must provide with this notice a Material Safety Data Sheet for all of the explosives or SSAN detailed in the notice.
·  A certificate of analysis (signed by the licence holder) must be provided (SSAN only, if required by the Chief Officer [r. 19]). /

Relevant international requirements

For the purposes of these regulations ‘relevant international requirements’ means:
·  for explosives transported by water – the latest edition of the International Maritime Dangerous Goods Code published by the International Maritime Organisation; and
·  for explosives transported by air – the latest edition of the Dangerous Goods Regulations published by the International Air Transport Association.

Retention action for notices

·  Licence holders must retain records of all exported explosives for 2 years after the date of the export.
·  Licence holders must retain copies of all SSAN export notices for 5 years after the date of export.

1. Consignee/consignor details

Consignee (holder of licence to import or export explosives or SSAN)

Name
Import / export licence number / Explosives SSAN
Business address
Phone no. / Facsimile
Mobile phone no. / Email

Consignor (the overseas company that receives the goods)

Name
Business address (in country where goods shipped to)
Phone no. / Email

2. Product details

Product / Quantity / Class / UN number /

(If insufficient space, please add a separate sheet)

3. Export details

Country being exported to
Mode of exit from Western Australia (please complete one of the following boxes)
Sea / OR / Air
Name of ship / Name of carrier
Flight number
Expected date of departure / DD / MM / YYYY
Name of port or place the explosives or SSAN will depart

4. Certification

I certify that the explosives being exported as detailed in this notice are:

·  being exported in accordance with the law of the country named (attached certificate)

·  packaged in accordance with the relevant international requirements

·  in a safe condition to be transported.

Full name (please print)
Signature of applicant / Date / DD / MM / YYYY

5. Licence holder declaration

I declare that the information contained in this notice is true and correct.

Full name (please print)
Position / Phone (day)
Email
Signature / Date signed / DD / MM / YYYY

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