<p> PORTS OF DAMPIER & ASHBURTON THIRD PARTY USE OF A MOORING</p><p>Before completing this Third Party agreement, please contact PPA to confirm the mooring swing radius. Email [email protected] or phone 08 9159 6528</p><p>Please refer to the Moorings Handbook and the Mooring Licence Terms and Conditions when completing this form. </p><p>SECTION 1 - TO BE COMPLETED BY THE MOORING OWNER Mooring details</p><p>Mooring Number:</p><p>Mooring Type: Cyclone Non-Cyclone Longitude Mooring Location GPS: Deg, dec min : Mooring Swing Radius: Date of Last Mooring Inspection: Mooring Licence Number: Mooring Licence Expiry Date:</p><p>Mooring Owner Details</p><p>Company Name: Contact Person: Address: Postal Address: Phone: Email Address:</p><p>SHEQ-SYS-F-131 Issued Date: 11/08/2014 Rev No: 4 Page: 1 of 5</p><p>PORTS OF DAMPIER & ASHBURTON THIRD PARTY USE OF A MOORING</p><p>Mooring Number: Mooring Responsibilities</p><p>Start Date: End Date:</p><p> rd Who is responsible for maintenance? Owner 3 Party User</p><p> rd Who is responsible for annual reporting? Owner 3 Party User</p><p> rd Who is responsible for payment of fees, charges and fines? Owner 3 Party User</p><p> rd Who do we contact for issues arising from this mooring? Owner 3 Party User PPA Requirement A mooring/vessel analysis has been obtained from the Naval Architect? Yes (please attach)</p><p>Mooring Owner Declaration</p><p>In signing this declaration the mooring owner confirms that: (a) the stated third party has permission to use this mooring as outlined in Section 2, Section 6 and Section 7 of the Moorings Handbook, (b) the third party has been advised of the condition, available swing radius and licencing status of the mooring, and (c) all parties are aware of their responsibilities and obligations as set out in the Moorings Handbook and Mooring Licence Terms and Conditions.</p><p>Signature:</p><p>Name (print):</p><p>Date:</p><p>SHEQ-SYS-F-131 Issued Date: 11/08/2014 Rev No: 4 Page: 2 of 5</p><p>PORTS OF DAMPIER & ASHBURTON THIRD PARTY USE OF A MOORING</p><p>Mooring Number: SECTION 2 - TO BE COMPLETED BY THE THIRD PARTY Third Party Details</p><p>Company Name: ABN: Contact Person: Address: Postal Address: Phone: Mobile: Email Address:</p><p>Third Party Vessel Details</p><p>Name of Vessel: Type of Vessel:</p><p>Gross Tonnage: LOA(metres): Hull Type: Draft: IMO/Registration Number: Total Swing Length of Hawser (metres): Radius: Condition of Hawser: Hawser Specifications:</p><p>NB: Hawsers must be as per the Naval Architects recommendation. Hawsers must not be left floating free from moorings to prevent damage to other craft.</p><p>Third Party User Declaration</p><p>In signing this declaration the third party user confirms that: (a) the mooring will be used as per the mooring responsibilities stated in Section 1 above; (b) is aware of the condition, available swing radius and licencing status of the mooring, and (c) the responsibilities and obligations of using the mooring as set out in the Moorings Handbook and Mooring Licence Terms and Conditions are understood, including the requirement of annual inspections and licencing.</p><p>Signature:</p><p>Name (print):</p><p>SHEQ-SYS-F-131 Issued Date: 11/08/2014 Rev No: 4 Page: 3 of 5</p><p>PORTS OF DAMPIER & ASHBURTON THIRD PARTY USE OF A MOORING</p><p>Date: Please forward this form and supporting documentation to [email protected] for approval.</p><p>SHEQ-SYS-F-131 Issued Date: 11/08/2014 Rev No: 4 Page: 4 of 5</p><p>PORTS OF DAMPIER & ASHBURTON THIRD PARTY USE OF A MOORING</p><p>Mooring Number: SECTION 3 - PPA APPROVAL</p><p>In signing this declaration, PPA confirms that a mooring/vessel analysis has been received and the vessel is within the mooring swing radius of .</p><p>Additional Comments: </p><p>Signature:</p><p>Name (print):</p><p>Position:</p><p>Date:</p><p>SHEQ-SYS-F-131 Issued Date: 11/08/2014 Rev No: 4 Page: 5 of 5</p>