Traffic Management Plan Submission Form Details of company submitting the Traffic Management Plan Company Name Address Contact Name Address Mobile Number Phone Number Fax Number Date Signature of applicant Work Zone Details Road 1 Traffic Volume (vpd) Road sections affected by the proposed works Road 2 Traffic Volume (vpd) Suburb Description of proposed works Site supervisor Site supervisor contact name contact number Times the proposed Start Am/Pm Finish Am/Pm TMP will be in operation Start Date Finish Date Duration of work Weekdays Yes / No Weekends Yes / No Require deviation of vehicular traffic into an on-coming Yes / No traffic lane? Be conducted on, partly on or affect a bridge or other Will the works: Yes / No structure? Cause significant delay (5 minutes or more) to traffic on Yes / No an arterial road or municipal road? How long will closure of the road or part of the road to vehicular traffic A continuous period of more than 12 Yes / No be required for? *NOTE: An afterhours TMP plan will need to be submitted if the worksite is to remain under More than 24 hours in a 7 day period? Yes / No changed traffic conditions overnight.
Traffic Management Plan Submission Form Details of company submitting the Traffic Management Plan Company Name Address Contact Name Address Mobile Number Phone Number Fax Number Signature of applicant Date Work Zone Details Road sections affected by the proposed works Road 1 Traffic Volume (vpd) Road 2 Traffic Volume (vpd) Suburb Description of proposed works Site supervisor contact name Site supervisor contact number Times the proposed TMP will be in operation Start Am/Pm Finish Am/Pm Duration of work Start Date Finish Date Weekdays Yes / No Weekends Yes / No Will the works: Require deviation of vehicular traffic into an on-coming traffic lane? Yes / No Be conducted on, partly on or affect a bridge or other structure? Yes / No Cause significant delay (5 minutes or more) to traffic on an arterial road or municipal road? Yes / No How long will closure of the road or part of the road to vehicular traffic be required for? *NOTE: An afterhours TMP plan will need to be submitted if the worksite is to remain under changed traffic conditions overnight. A continuous period of more than 12 Yes / No More than 24 hours in a 7 day period? Yes / No
traffic_management_application_form.docx