| WHS (MINES AND PETROLEUM SITES) LEGISLATION Appointment and notification of operator of a mine or petroleum site April 2018 This form must be completed by the mine holder or petroleum site holder, including when that holder is the operator of the mine or petroleum site. Read the or before completing this form. Details of mine or petroleum site Name of mine or petroleum site Site address of mine or petroleum site Type of notification New mine or petroleum site Appointment of a new operator of a mine or petroleum site. What is the name of the previous operator? Change of name of an existing mine or petroleum site. What was the previous name of the mine or petroleum site? Land title identification reference(s)
| WHS (MINES AND PETROLEUM SITES) LEGISLATION Appointment and notification of operator of a mine or petroleum site April 2018 This form must be completed by the mine holder or petroleum site holder, including when that holder is the operator of the mine or petroleum site. Read the or before completing this form. Details of mine or petroleum site Name of mine or petroleum site Site address of mine or petroleum site Type of notification New mine or petroleum site Appointment of a new operator of a mine or petroleum site. What is the name of the previous operator? Change of name of an existing mine or petroleum site. What was the previous name of the mine or petroleum site? Land title identification reference(s)