Western Australian Consolidated Regulations

GAS STANDARDS (INFRINGEMENT NOTICES) REGULATIONS 2007 - SCHEDULE 2

[r. 4]

Form 1 — Infringement notice

Gas Standards Act 1972 Infringement notice		Infringement notice no.
Alleged offender	Name:         Family name
	Given names
	or         Company name ____________________________________                 ACN
	Address ________________________________________________         Postcode
Alleged offence	Description of offence _____________________________________
	Gas Standards Act 1972 s.  Gas Standards (Gasfitting and Consumer Gas Installations) Regulations 1999 r.  Gas Standards (Gas Supply and System Safety) Regulations 2000  r.
	Date         /         /20         Time         a.m./p.m.
	Modified penalty $
Officer issuing notice	Name
	Signature
	Office
Date	Date of notice         /         /20
Notice to alleged offender	It is alleged that you have committed the above offence. If you do not want to be prosecuted in court for the offence, pay the modified penalty within 28 days after the date of this notice.
	How to pay By post: Send a cheque or money order (payable to ‘Director of Energy Safety’) to: Director of Energy Safety [Address]
	In person: Pay the cashier at: Energy Safety [Address]
	If you do not pay the modified penalty within 28 days, you will be prosecuted or enforcement action will be taken under the Fines, Penalties and Infringement Notices Enforcement Act 1994 . Under that Act your driver’s licence and/or vehicle licence may be suspended.
	If you need more time to pay the modified penalty, you can apply for an extension of time by writing to the Director of Energy Safety at the above address.
	If you want this matter to be dealt with by prosecution in court, tick this box ❑ and post this notice to the Director of Energy Safety at the above address within 28 days after the date of this notice.

Form 2 — Withdrawal of infringement notice

Gas Standards Act 1972 Withdrawal of infringement notice		Withdrawal no.
Alleged offender	Name:         Family name
	Given names
	or         Company name _____________________________________                 ACN
	Address _________________________________________________         Postcode
Infringement notice	Infringement notice no.
	Date of issue         /         /20
Alleged offence	Description of offence ____________________________________
	Gas Standards Act 1972 s.  Gas Standards (Gasfitting and Consumer Gas Installations) Regulations 1999 r.  Gas Standards (Gas Supply and System Safety) Regulations 2000  r.
	Date         /         /20         Time         a.m./p.m.
Officer withdrawing notice	Name
	Signature
	Office
Date	Date of withdrawal         /         /20
Withdrawal of infringement notice	The above infringement notice issued against you has been withdrawn. If you have already paid the modified penalty for the alleged offence you are entitled to a refund.
[*delete whichever is not applicable]	*         Your refund is enclosed. or *         If you have paid the modified penalty but a refund is not enclosed, to claim your refund sign this notice and post it to: Director of Energy Safety [Address] Signature         /         /20