DAGEROUS GOODS ACT 1985 DAGEROUS GOODS (TRASPORT B ROAD OR RAIL) REGULATIOS 2018 Jan 2018 WORKSAFE VICTORIA APPLICATIO FOR A VEHICLE LICECE TO TRASPORT DAGEROUS GOODS - FTL Office use only checklist (please circle) Please refer to General Information and Instructions at the end of this form for guidance on completing and submitting this application. 1. Application Type (Tick application type) I wish to apply for: A Vehicle Licence to Transport Dangerous Goods Renewal of my Vehicle Licence to Licence o. Date of Expiry Transport Dangerous Goods Amendment to my Vehicle Licence to Licence o. Date of Expiry Transport Dangerous Goods Please specify amendment details Application type completed? A Replacement Vehicle Licence to Transport Dangerous Goods because the licence has been Lost Stolen Destroyed Other (please specify) Licence o. Date of Expiry 2. Applicant Details Full Legal ame of Organisation Is part 2 AB/AC Office Address Postal Address Contact Person ame Telephone Mobile Facsimile Email Address 3. Additional Applicant Details Are you subject to any court order or proceedings that prohibits you from involvement in the transport of dangerous goods by road? Is part 3 es o If yes, please complete the following Date prohibition imposed: State / Territory imposing prohibition: 4. Vehicle Details Type of Vehicle/s: Tank Vehicle Complete section 5 (tick one box only) Other Vehicle Complete section 6 Is part 4 OTE: Other Vehicle includes any rigid vehicle or trailer that is OT a tank vehicle. Prime movers are not required to be licensed.
5. Vehicles of which a Tank forms part of, or to which a Tank is attached to, Transporting Dangerous Goods Is part 5 OTE: In accordance with Section 210 of the Dangerous Goods (Transport by Road or Rail) Regulations 2018, the vehicle must be registered in, and operate exclusively or predominantly within Victoria. (a) A self assessment, against the requirements of Chapter 6 of the Australian Dangerous Goods code, has been conducted for each tank, forming part of or attached to a vehicle listed in the table below and meets the relevant requirements of the Code. A record of the self assessment has been maintained and is available for inspection by the relevant Authority if requested. (b) For each tank, forming part of or attached to a vehicle transporting Dangerous Goods, please provide the following: (refer to the general information and instructions page at the back of the form). Existing Licence Expiry Date Victorian Vehicle Manufacturer of Tank Tank Tank Design State or If interstate, Classes of o. (FTL) (if applicable) Registration Type* Approval Territory Copy of dangerous goods (if applicable) umber (see umber Issue of Tank Design the tank design is below) Approval Approval approved to carry Letter attached? Is vehicle registered in Victoria? Tank Type* TR Tank, Rigid TS Tank, Semi-Trailer TT Tank Trailer, Dog Trailer
6. All other Vehicles Transporting Dangerous Goods OTE: In accordance with Section 210 of the Dangerous Goods (Transport by Road or Rail) Regulations 2018, the vehicle must be registered in, and operate exclusively or predominantly within Victoria. Is part 6 Existing Licence Expiry Date Victorian Vehicle Manufacturer of Vehicle Other Vehicle Classes of dangerous goods to be umber (FTL) (if applicable) Registration umber Type** be transported (if applicable) (see below) (refer to general info page) Is vehicle registered in Victoria? Other Vehicle Type** RT Rigid, Tray Truck ST - Semi-Trailer, Flat Tray, Drop Deck, Skeleton RV Rigid, Van Body SP - Semi-Trailer, Pantechnicon RC Rigid, Curtain Side SC - Semi-Trailer, Curtain Side RB Rigid, Bulk Bin SB - Semi-Trailer, Bulk Bin ote: Semi-Trailer includes a unit of a B-Double combination.
7. Declaration and Consent by Applicant Consent I consent to the collection of personal information by WorkSafe Victoria for the purposes outlined in the section headed Collection of Personal Information on this form, including collection from a law enforcement agency of information about any criminal convictions, criminal proceedings commenced against me and other relevant matters recorded against my name in the records of the agency. I consent to the disclosure of such information to the types of organisations listed in the Collection of Personal Information statement for any purposes listed in that statement. Declaration signed and dated? Declaration I declare that, to the best of my knowledge, the information provided in this application and supporting this application is true and correct in every particular. I declare that where I provide personal information to WorkSafe Victoria about any other individual, I am authorised to provide that information, the information has been collected in accordance with the Information Privacy Act 2000 (Vic) and the individual has been or will be made aware of WorkSafe Victoria s identity and how to contact it and of the other matters of which an individual is required to be made aware when personal information is collected about them. Applicant s Signature Witnessed by (signature) - witness must be at least 18 years of age Date Print Witness ame Telephone Witnessed? WARIG: The provision of false and misleading information is an offence under the legislation 8. Checklist Use this checklist to ensure that your application is complete: Application form, completed, signed, witnessed and dated; and Copy of any associated tank approval(s) attached; and Required fee OTE: Unsigned or incomplete applications or applications not accompanied by the required documentation may not be processed. 9. Payment Options The application must be accompanied by a fee of 0.98 fee units for each road vehicle requiring a licence or a renewal of a licence. A fee unit is a dollar amount set under the Monetary Units Act 2004 each financial year that is used to calculate certain statutory fees. ou can check the current application fee, and the current value of a fee unit, at worksafe.vic.gov.au. Fees can be paid by cheque, money order, MasterCard, or VISA. Cheques should be made payable to the Victorian WorkCover Authority. (There is no amendment or replacement fee). WorkSafe Victoria s AB is 90 296 467 627 Fee paid? Receipt o? Paying by mail I wish to pay by: Cheque OR Money order Make cheque/money order payable to WorkSafe Victoria. Paying by credit I wish to pay by credit card. Please charge payment of $ to my: Receipt date? / / Mastercard Visa Card o. Expiry date Cardholder name Signature
General Information and Instructions A Vehicle Licence to Transport Dangerous Goods (FTL) is issued in accordance with the Dangerous Goods (Transport by Road or Rail) Regulations 2018. A copy of the Regulations can be downloaded from www.dms.dpc.vic.gov.au, or can be obtained from Information Victoria (1300 366 356). 1. When a Licence is Required A vehicle licence is required when a road vehicle is used to transport: a) dangerous goods that are in a receptacle with a capacity of more than 500 litres; or b) more than 500 kilograms of dangerous goods in a receptacle. 2. IBC s A vehicle licence is not required for the transport of dangerous goods in IBC s provided that the IBCs are not filled or emptied while on the vehicle and their total volume is not greater than 3,000 litres. 3. Packaged Dangerous Goods A vehicle licence is not required for the transport of packaged dangerous goods. 4. Prime Movers A vehicle licence to transport dangerous goods is not required for the prime mover of a semi-trailer or combination vehicle. 5. Transfer of Licence A licence cannot be transferred. If you obtain a vehicle that is already licensed under another organisation then you must apply for a new licence. A licence cannot be transferred from one vehicle to another. 6. Change of Registration Details An amendment must be submitted if the vehicle registration number changes. 7. Cancellation A licensee must notify WorkSafe Victoria in writing when a vehicle has been sold, disposed of, or no longer used to transport dangerous goods. 8. Mutual Recognition A current Vehicle Licence to Transport Dangerous Goods is recognised in every State and Territory in Australia and you do not need a licence issued by other States or Territories in order to transport to or between these States or Territories. 9. Applicant Details The applicant must be a legal entity, such as an individual (or individuals), a company, a body corporate or a public authority. The following are not legal entities a partnership name, joint venture name or trading name. 10. Vehicle Type A tank vehicle is a vehicle having a tank as an integral part of the vehicle or where the tank is not designed to be readily removed from the vehicle. Other vehicle type includes any semi-trailer or other vehicle that is not a tank vehicle. 11. Tank Design Approval umber Every tank design must be approved, and a design approval number is issued by a relevant Authority. This approval is in addition to any approval for a pressure vessel in accordance with chapter 6.9 of the Australian Dangerous Goods Code. The tank design approval number can be located on the tank compliance plate fitted by the manufacturer in accordance with chapter 6.9 of the ADG Code. A copy of the tank design approval letter must be provided. 12. Dangerous Goods Classes A tank vehicle can only carry the class/(es) for which its design has been approved. 1 Explosives 2.1 Flammable gas 2.2 on-flammable non-toxic gas 2.3 Toxic gas 3 Flammable liquids 4.1 Flammable solids 4.2 Spontaneously combustible substances 4.3 Dangerous when wet substances 5.1 Oxidising agents 5.2 Organic peroxides 6.1 Toxic substances 6.2 Infectious substances 7 Radioactive material 8 Corrosives 9 Miscellaneous substances 13. Explosives This Application for a Vehicle Licence to Transport Dangerous Goods does not cover Class 1 (explosives). A separate licence is required - please contact WorkSafe Victoria to obtain an Application for a Vehicle Licence to Transport Explosives form. Licence OK to issue? Licence o Date of issue / / Officer Signature Audited by Date of Audit / / Checklist Complete?
Collection of Personal Information Personal information collected by WorkSafe Victoria in connection with this application will be used for the purpose of assessing the application and administering the licence. The information may also be used for the administration and enforcement of legislation administered by WorkSafe Victoria, administration and evaluation of WorkSafe Victoria s programs generally, and legal proceedings. WorkSafe Victoria may disclose personal information to its contractors and agents; to a court or tribunal; to other regulatory agencies (including police, for the purposes of investigating or conducting an interview in connection with the application); and to any person authorised by the individual to whom it relates, or by law, to obtain it. WorkSafe Victoria may disclose a persons licence status to employers or prospective employers and members of the public who wish to check this status. Collection of this information may be required by the Victorian Dangerous Goods Act 1985 and Dangerous Goods (Transport by Road or Rail) Regulations 2018. ou have rights to access any personal information that WorkSafe Victoria holds about you. Please contact the WorkSafe Freedom of Information Unit for more information. ou can access the WorkSafe Privacy Policy at www.worksafe.vic.gov.au. 10. Contact Details Submit your completed application form to: WorkSafe Victoria Telephone 1300 852 562 Licensing Branch Facsimile 1800 060 727 PO Box 279 Email licensing@worksafe.vic.gov.au Geelong VIC 3220 Further information relevant to this vehicle licence to transport dangerous goods is available on our website www.worksafe.vic.gov.au WorkSafe Victoria is a trading name of the Victorian WorkCover Authority FOR518/07/09.18