Application to operate a diesel engine underground (F-0011)

Home
Forms
Application to operate a diesel engine underground

Application to operate a diesel engine underground

Before using a diesel engine in any underground mine or project, an application form as prescribed by the board shall be completed and submitted.” (this is a direct quote from section 15.58(2) of the WSCB regulation Part 15 - Surface and Underground Mines or Projects)

Download Printable Form

This information is being collected for the purpose of administering and enforcing the Workers’ Safety and Compensation Act in compliance with the Access to Information and Protection of Privacy Act. If you have any questions about the collection of this information, please contact the board’s Privacy Officer at 401 Strickland St., Whitehorse, YK, Y1A 5N8 or call 867-667-5642 or 1-800-661-0443.

Workplace Information

Name of Mine

Physical address of Mine

Primary phone number

Business Point of Contact Information

Company Name

Street Number

Street Name

City

Province/Territory

Postal Code

Primary phone number

Equipment Information

Type of Equipment

e.g. Jumbo, Scooptram

Unit Number

Manufacturer

Model

FOPS certification or standard information

Overall Dimensions of Equipment

Length

Width

Height

Fire Extinguishing Equipment

Type

Size

Location

Fire Suppression System

Hydraulic Fluids

Type

Quantity

Function

Maximum grade equipment will be operated on

Engine Information

Manufacturer

Model

Horsepower

Engine Serial Number

Starting Mechanism

Details of Approval Plate or Certificate, including ventilation (CFM) requirements from CANMET or MSHAW.

Details of Exhaust Conditioning

Type of Conditioner

Location of repair and fueling arrangements (submit plan if underground)

Signature, consent, declaration

By checking this box I declare that the information provided is true and correct.

My name

My email

I am the mine manager

Yes No