Proforma for Notification of Minor Changes to a Mining Proposal

To Team Leader Name: ______________________Resource and Environmental Compliance DivisionDepartment of Mines, Industry Regulation and Safety

This pro forma is designed to allow proponents to notify Department of Mines, Industry Regulation and Safety (DMIRS) of minor changes to a Mining Proposal that they consider to not require approval via a revised Mining Proposal.

ENVIRONMENTAL GROUP SITE (EGS) DETAILS

EGS Name

EGS CodeCode is derived from the EARS2 system.

APPLICANT DETAILS

Company or Individual Name

Tenement Holder(s) (if different from above)

MINING PROPOSAL DETAILS

Registration IDID is derived from the EARS system.MP dateApplication Lodgement Date

DETAILS OF PROPOSED CHANGES (e.g. minor changes to environmental management practices, environmental monitoring, location of infrastructure, etc.).

TENEMENT DETAILS

Tenements subject to the changeState ‘all’ if relevant to all tenements of the EGS

Tenement Tenement Holder

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CHECKLIST TO CONFIRM WHETHER OR NOT A REVISED MINING PROPOSAL IS REQUIRED

Yes/No Explanation/Justification

Is disturbance proposed outside of the disturbance envelope in the approved mining proposal (e.g. a project expansion)?Do any aspects of any ‘Key Mine Activities' detailed in the approved Mining Proposal need to change?Is a new activity or change to an activity type proposed from that approved in the Mining Proposal?

Corporate Endorsement: “I hereby certify that to the best of my knowledge, the information within this form is true and correct”

Name: ________________________ Signed: ______________________

Position: ______________________ Date: ________________________

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