Crafco Crack Sealer Permit

Permit ID

Before performing any crack sealing works, all contractors, tenants and ADG staff must complete this Permit and have it approved. The purpose of this Permit is to ensure that all safety aspects of crack sealing have been considered and actioned.

Status

Are you or your business registered with ADG? *

YesNo

Note: registration is necessary before any work on ADG Leased Area is permitted.

*Please register your business with ADG before proceeding. Please click here to register.

Have you completed the Working on Airport induction? *

YesNo

*Please complete the Working on Airport induction before proceeding with the application.

Part 1 – Application Details

Assessor *

Select Airport *

Business Name *

Applicant Name *Person in Charge of Works

Date Applied *

Email **Applicant's email address

Phone number *

ADG Point of Contact/ Project Manager Details

ADG Point of Contact Name *

ADG Point of Contact Phone Number *

ADG Project Manager Email *

Other PM Email *

Part 2 – Description of Works

Location of Works *

Start Date of Works *

End Date of Works *

*End date of works should be after the start date of works.

Hours of Work (From) *

Hours of Work (To) *

Describe the planned works *

Start and End Date of Works validation

Part 3 – Before Crack Sealing Checklist

Operations Department notified for airside works? *

Yes No

Name of the notified person *

Comments

PPE worn (e.g. long sleeves, gloves, safety glasses, goggles)? *

YesNo

Comments

First aid prepared (e.g. 15L water, first aid kit, drinking water)? *

YesNo

Comments

Emergency Plan (for fire & evacuation) developed and provided? *

YesNo

Comments

Operator trained and competent? (Note their name) *

YesNo

Trained Operators Names *

Comments

‘Communication Person’ assigned for ATC? *

YesNo

ATC Communication Person Name *

Comments

Pre-start check for fuel, water and oil done? (Very important) *

YesNo

Comments

Ventilation machine placed so fumes blown away from operators? *

YesNo

Comments

Fire equipment checked and in place? *

YesNo

Comments

Pre-start risk assessment (SWMS) done? *

YesNo

Attach SWMS *

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Comments

Part 4 – Acknowledgement of Applicant

I confirm that:

I understand the hazard of this work and the precautions to be taken and the hazards and precautions listed above have been discussed with the work team.
I agree to comply with all work health and safety requirements as outlined in our SWMS.
I will return my copy of this Permit for cancellation by the ADG Authorised Person, once work has been safely completed.

Name of Applicant *

Signature *

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Applicant's Signature Date

Part 5 – Authorisation to Work

Is the permit approved? *

YesNoMore Information Required

Notes to the applicant *

Preliminary site inspection by ADG Authorised Person?

YesNo

I authorise the works listed above to proceed during the specified dates and times. *

Name and Title of ADG Authorised Person *

Phone Number *

Authorised Person's Signature *

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Date and Time ADG Authorised Person

Part 6 - Work Party Sign On and Off

Each worker using the crack sealing machine must read and acknowledge the requirements of this permit prior to use.

Worker's Full Name	Sign On (Date and Time)	Sign Off (Date and Time)

Note: If anyone has an accident or adverse reaction to the inhalation of fumes, immediately report it to the ADG Health & Safety Manager (safety@adgnt.com.au or 0402 782 375).

Part 7 – Cancellation of Permit from Person in Charge of Works

Cancellation Date and Time *

Please attach a photo of the site. *

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Please attach a photo of Work Party Sign On and Off (Part 6) *

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I confirm that: *

The works described in this Permit have been satisfactorily completed, or stopped and made safe.

Shut Down procedures were followed. *

The machine has been cleaned, packed up, and stored. *

Any repair or maintenance required on the machine has been noted *

This Permit is now cancelled. *

Name of Person in Charge of Works *

Signature (Person in Charge of Works) *

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Person in Charge of Works Signature Date

Part 8 - Cancellation of Permit ADG Authorised Perosn

Name of ADG Authorised Person *

Date *

Signature *

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CAPTCHA *

*Please fix the date above

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