This notice is required to be submitted under regulations 33(3) and 33(4) of the Petroleum (Environment) Regulations 2016 (the Regulations) and may be published in accordance with regulation 35A(1)(a) of the Regulations. Send the completed form to Onshoregas.DEPWS@nt.gov.au either no later than 2 hours after the incident first occurred or the interest holder became aware of the incident, or if the initial notice was provided orally, no later than 24 hours after giving an oral notice.

Section 1 – Interest Holder Details
For petroleum titles held by multiple interest holders, details must be completed for each interest holder. If insufficient room, please attach information to the form.
Interest Holder 1	Interest Holder 2	Interest Holder 3	Interest Holder 4
Company Name
Nominated interest holder for all matters related to Notice? If ‘no’ each interest holder must sign Declaration and will receive related documents unless designated operator authorised to sign and receive documents	☐ Yes ☐ No	☐ Yes ☐ No	☐ Yes ☐ No	☐ Yes ☐ No
Authorisation given to an Operator to submit Notice and sign Declaration?	☐ Yes ☐ No	☐ Yes ☐ No	☐ Yes ☐ No	☐ Yes ☐ No

Section 2 – Reportable Incident Notice Details
EMP title (petroleum title/s)	Unique EMP ID	Oral notice provided	☐ Yes ☐ No
Activity type	Time submitted	Date Submitted
Incident date	Incident time	Date and time interest holder became aware

Section 3 – Reportable Incident Details
Reg 33(3)(c)(ii): All material facts and circumstances about the reportable incident that the interest holder knows or is able, by reasonable search or enquiry, to find out Refer to Section 6.2.1.1 of the Onshore Petroleum Incident Reporting Guideline	Supporting information attached ☐ Yes ☐ No
Reg 33(3)(c)(iii): Any action taken to avoid or mitigate material or serious environmental harm Refer to Section 6.2.1.2 of the Onshore Petroleum Incident Reporting Guideline	Supporting information attached ☐ Yes ☐ No
Reg 33(3)(c)(iv): Corrective action taken, or proposed, to prevent a similar reportable incident occurring Refer to Section 6.2.1.3 of the Onshore Petroleum Incident Reporting Guideline	Supporting information attached ☐ Yes ☐ No

Section 4 - Declaration
A person with legal authority to sign on behalf of the interest holder, or all interest holders (if more than one), must sign the declaration. I hereby declare that I: am authorised to make this declaration. confirm that, to the best of my knowledge all information provided addresses the relevant matters and is true, correct, complete, and does not contain misleading information am aware that it is an offence under section 107 of the Petroleum Act 1984 to give an authorised person information that I know, or ought to reasonably know, to be false or misleading in a material manner particular understand that all information supplied as part of this form, including attachments, may be disclosed publically in accordance with regulation 35A of the Petroleum (Environment) Regulations 2016, and consistent with the requirements of the Information Privacy Principles (IPPs) in the Information Act 2002.
If notice being signed by interest holder/s (include attachment if more room is required to complete the below table)
Interest Holder 1	Interest Holder 2	Interest Holder 3	Interest Holder 4
Company Name
Signature
Name (print)
Position
Date
Email
If notice being signed by Operator on behalf of interest holder/s
Operator details (if applicable)
Company Name	ABN/ACN
Signature	Address
Name (print)	Email
Position