This notice is required to be submitted under regulations 34(3) and 34(6) of the Petroleum (Environment) Regulations 2016 (the Regulations). If an Initial Report, submit to Onshoregas.DEPWS@nt.gov.au as soon as practicable but not later than three days after the reportable incident first occurs (regulation 34(3)(a) of the Regulations), or, if an Interim Report, submit within 90 days of the initial report and thereafter at intervals of 90 days, unless otherwise agreed with the Minister (regulation 34(7) of the Regulations).

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 Report? 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 Report and sign Declaration?	☐ Yes ☐ No	☐ Yes ☐ No	☐ Yes ☐ No	☐ Yes ☐ No

Section 2 – Reportable Incident Report Details
EMP title (petroleum title/s)	Unique EMP ID	Initial report	☐ Yes ☐ No
Activity type	Time submitted	Interim report	☐ Yes ☐ No
Incident date	Date submitted	Interim report #

Section 3 – Reportable Incident Details
Reg 34(3)(b)(i): Result of any assessment/ investigation of the conditions/circumstances that caused or contributed to the reportable incident’s occurrence, including assessment of effectiveness of designs, equipment, procedures and management systems that were in place to prevent occurrence Refer to Section 6.2.2.1 of the Onshore Petroleum Incident Reporting Guideline	Supporting information attached ☐ Yes ☐ No
Reg 34(3)(b)(ii): Nature and extent of material or serious environmental harm that the incident caused or could cause Refer to Section 6.2.2.2 of the Onshore Petroleum Incident Reporting Guideline	Supporting information attached ☐ Yes ☐ No
Reg 34(3)(b)(iii): Any actions taken or proposed to clean up or rehabilitate an area affected by the incident Refer to Section 6.2.2.3 of the Onshore Petroleum Incident Reporting Guideline	Supporting information attached ☐ Yes ☐ No
Reg 34(3)(b)(iv): Any actions taken or proposed to prevent recurrence of an incident of a similar nature Refer to Section 6.2.2.4 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 report 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 report being signed by Operator on behalf of interest holder/s
Operator details (if applicable)
Company Name	ABN/ACN
Signature	Address
Name (print)	Email
Position