Application to amend a water monitoring authority

Application to amend a water
monitoring authority
No. (Office Use Only)
Petroleum and Gas (Production and Safety) Act 2004
(s203), Petroleum Act 1923 (s75WN)
MINES ABN 59 020 847 551
Form MMOL-38 Version 1
You may make an application to amend a water monitoring authority electronically using the MyMinesOnline system. Alternatively you
may complete the original of this application and submit the application, any attachments and the prescribed fee at a Mines lodgement
office.
Note: A document containing information that is false or misleading may attract a maximum penalty of 200 penalty units.
Please use a pen, and write neatly using BLOCK LETTERS Cross where applicable
The holder of a water monitoring authority may apply to amend it to increase or decrease its area or to add or omit or reflect an amendment of
a petroleum tenure that relates to the authority
Question 1 – Permit and holder details (Authority to Prospect, Petroleum Lease WMA relates to)
Permit number (eg PL1):
Current expiry date:
Detail the current holder(s)
Holder 1
Holder 2
Holder 3
Company
Name/surname:
Given name (if
individual):
ACN/ARBN
% Holding:
Question 2 – Amendment details
2.1 Is this an application to amend the size of the area of the water monitoring authority?

Yes

No
If yes, provide area details below
OFFICE USE ONLY
Fees paid:
Payment Method:
Received at: ________________
Total $ _______
Cash
Received by:
DNRM
Credit Card
Receipt No.
EFTPOS
Receiving officer
I confirm that:
•
the details on application form have been checked;
•
all attachments have been submitted;
•
correct application fees have been submitted for the
relevant application type
Name: ___________________________
______________
Cheque
Signed:___________________________ Date:
Date:
Time:
/
/
AM/PM
/
/
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2.2 Specify the proposed new area for the permit
BIM/BLOCK
All
A
B
C
D
E
F
G
H
J
K
L
M
N
O
P
Q
R
S
T
U
V
W
X
Y
Z
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Total number of sub-blocks
Attachments required:
• Provide details about why the proposed amended land, required for the water monitoring authority, is required
to comply with, or assess the need to comply with the make good obligation (label as section 1)
2.3 Is this an application to add or omit, or reflect the amendment of, a petroleum tenure
that relates to the water monitoring authority?

Yes


Attachments required:
• If yes - Provide details about the addition or omission of, or amendment to, a petroleum tenure that relates to
the water monitoring authority (label as section 2)
No

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Question 3 –Obligations and declaration
•
•
•
•
I have read and understood the relevant guides.
I understand my obligations as an applicant/holder.
I have truthfully declared all relevant details requested of me in this application.
If any part of this form has been completed with the assistance of another person, I declare that the information as set
down is true and correct and has been included with my full knowledge, consent and understanding.
Note: if this form is being signed by a person other than the current registered holder, a letter of authority or power of
attorney documents must be provided with this application.
Print name:
Signature:
Position:
Date:
Company:
Print name:
Signature:
Position:
Date:
Company:
Print name:
Signature:
Position:
Date:
Company:
Print name:
Signature:
Position:
Date:
Company:
Question 4 – Payment
Application
Amend water monitoring fee

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OFFICE USE ONLY CHECKLIST -
YES/NO/NA
Has application details been provided as separate sections?
YES/NO/NA
Application fee has been lodged with application?
Receiving officer
I confirm that:
•
The details on this form have been checked
•
the checklist above are complete
•
attachments required are correct
•
correct fees have been submitted.
The application to amend a water monitoring authority has / has not
provided all the information required by the legislation to be
assessed.
I recommend that the application should / should not be received.
Name: ___________________________
Signed:___________________________
Date:
/
/
Reasons for refused to receive:
_______________________________________________________
Departmental Officer
The application to amend a water monitoring authority is received
and can be recorded on the register or refused to be received
under s842 of the P&G, s120 of the 1923 Act.
_______________________________________________________
_______________________________________________________
Name: ________________________________________
Signed:___________________________
Date:
/
/
Disclaimer
The Queensland Government Department is collecting information provided on this form for the purposes of assessing the suitability of your
application to amend water monitoring authority and maintain the public searchable register under the Petroleum and Gas (Production and Safety)
Act 2004 (‘the P&G Act’) and the Petroleum Act 1923 (the Act’). This information is authorised by sections 203 and 565 of the P&G Act and section
75WN and 80B of the Act. Some or all of this information may be provided to other agencies of the Queensland Government for the issuing of an
environmental authority, to make register searches, extracts or copies under section 566 of the P&G Act and section 80CA of the Act. Your
personal information will not otherwise be disclosed to any other third party without your consent, unless authorised or required by law.
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