applicant details - ntepa.nt.gov.au web viewthe premises are designed to produce more than 500,000...

Waste Management and Pollution Control Act (2009)

APPLICATION FOR AN ENVIRONMENT PROTECTION APPROVALPursuant to Section 31(2)

For guidance on completing this form, you should refer to the Guide to Environment Protection Approvals and Licences under the Waste Management and Pollution Control Act. The guide is available from the Northern Territory Environment Protection Authority (telephone 8924 4218) or on the website at www.ntepa.nt.gov.au

Information on this form is being collected in accordance with section 31 of the Waste Management & Pollution Control Act for the purpose of assessing your application for a licence under the Act. Failure to provide the information requested on this form may result in your application not being considered. Information is collected and managed in accordance with the Northern Territory Environment Protection Authority Privacy Statement and the Information Act. The privacy statement can be found at: www.ntepa.nt.gov.au

1. APPLICANT DETAILS

Proposed Approval HolderThe approval holder must be an individual(s), body corporate or public authority not a partnership, trust or joint-venture name.

Full name of Applicant who will Legally hold Approval

ABN ACN

Contact InformationAll official correspondence will be directed to this person.

Name Position

B/Hours Phone A/Hours Phone

Mobile Fax

Email

Business Address

Street Number

Suburb State Postcode

Postal Address

PO Box Suburb

State Post Code

DurationThe duration of this approval will in any event be subject to any statutory approval to commence activities provided by another Authority.

Please state the preferred number of years that you wish your approval to be in force.

Application for an Environment Protection Approval of 16Last Reviewed: Sept 11

EOFM-006-01

http://www.ntepa.nt.gov.au/


NORTHERN TERRITORY ENVIRONMENT PROTECTION AUTHORITY

2. EMERGENCY CONTACT

Please provide contact details for someone who can respond to an incident relating to the approved activity 24 hours a day.

Name Position


Mobile Fax

Email

3. ACTIVITY DETAILS

Please tick all activities that you are proposing to undertake and ensure that you attach all the appropriate supporting documentation as per section 9 of this form. Please refer to the Guide to Environment Protection Approvals and Licences Under the Waste Management and Pollution Control Act for clarification of activities.

Activity Regulation Reference Characteristics

A1 Solid Waste Disposal

Section 30, Schedule 2, Part 1(1)

Constructing, installing or carrying out works in relations to premises for disposal of waste by burial, other than:o Domestic waste generated by domestic residence and

disposed of on the land on which the premises is situated;o Domestic waste from temporary construction camps;o Waste generated by pastoral activities that is disposed of

on the land on which the pastoral activities are carried out;o Waste rock, rubble and other inert materials used for the

purpose of reclaiming land; ando Waste of a prescribed class.

A2 Listed Waste Disposal


Constructing, installing or carrying out works in relation to premises, other than a sewerage treatment plant, associated with disposal of listed waste (i.e. asbestos, tyres) on a commercial or fee for service basis.

A3Listed Waste Storing, Recycling and/or Treating


Constructing, installing or carrying out works in relation to premises, other than a sewerage treatment plant, associated with storing, recycling and/or treating listed waste on a commercial or fee for service basis.

A4 LNG or Methanol Plant


Constructing, installing or carrying out works in relation to premises for processing hydrocarbons to produce, store and/or dispatch liquefied natural gas (LNG) or methanol, where:o the premises are designed to produce more than 500,000

tonnes annually of LNG and/or methanol; ando no lease, licence of permit under the Petroleum Act or the

Petroleum (Submerged Land) Act relates to the land in which the premises is situated.

A5 Blacktip Gas Project


Constructing an onshore gas plant as part of the Blacktip Gas Project within the meaning of the Trans-Territory Pipeline and Blacktip Gas Projects (Special Provisions) Act 2005.

If you ticked activity A1 go to Section 4.If you ticked any of the activities from A2 to A3 complete Attachment 1 and go to Section 5.If you ticked any of the activities from A4 to A5 go to Section 5.

Application for an Environment Protection Approval of 16Last Reviewed: Sept 11


4. WASTE STREAMS

Please specify the population that your facility intends to service.

Please complete the following table.

Tick Waste Category Brief Description and SourcesQuantities per Annum

tonne m3

Municipal Solid Waste

Green Waste

Commercial & Industrial Waste

Construction & Demolition Waste

Listed Waste

If you ticked Listed Waste you must ensure that you have ticked Activities A2 and/or A3 as well as Activity A1 in section 3 and provide the relevant supporting documentation as specified in section 9 of this from.

5. LOCATION OF PREMISE TO BE LICENCED

Please attach a map showing the location, design and layout of the whole of the premises, and provide the following details of the location of the premises.

Premise commonly known as (if applicable)

Street Number Lot Number

Street Name Suburb

State Post Code

Title ReferenceFolio identifier or volume-folio (if Torrens Land System)

Registered deed number (if Old Land System)

Site Reference

Longitude Easting Latitude Northing

Point 1: Point 1:

Point 2: Point 2:

Point 3: Point 3:

Point 4: Point 4:

AMG Zone Reference System (GDA94, WGS84, AGD)

Local Government Area

If there are any conditions or restrictions placed on the usage of the land by either the owner or other authorities please provide details of these as an attachment.

Application for an Environment Protection Approval of 16Last Reviewed: Jan-13


6. CONSENT OF OWNER/OCCUPIER

If the applicant does not own the site, please provide details of the owner.

Full Name of Land or Premise Owner

Street Number Street Name

Suburb State Postcode


Mobile Fax

You must provide evidence that you have consent of the owner of the site to conduct this activity.

7. VEHICLE WASH FACILITIES

Will you have vehicle wash facilities? YES NO

If you answered ‘YES’ please attach plans and drawings for the facility including the type of oil/water separator, sediment and gross pollutant traps and any maintenance and performance monitoring schedules.

If you answered ‘NO’ please attach details of where you will be washing vehicles.



8. DISCHARGE POINTS

Will any of the activities you listed in Section 3 discharge pollutants to air, water or land? YES NO

If you answered ‘NO’ to this question, go to Section 9

If you answered ‘YES’ to this question, please attach a map of the premises showing the location of all discharge points for pollutants to air, water or land and identify each discharge point with a number.

If the discharge is to land for the purposes of irrigation, mark the area of land to which the discharge will be applied.

Discharges to AirPlease provide details of all discharge points to air.

Discharge Point 1 Discharge Point 2 Discharge point 3 Discharge Point 4

Label of discharge point on map

Longitude (decimal degrees)

Latitude (decimal degrees)

Easting (6 digits)

Northing (7 digits)

AMG Zone

Reference System (e.g. GDA94, WGS84, AGD)

Description of location of discharge point

Please ensure that all discharges to air have been included. Attach extra pages if more space is required.



Discharges to WaterPlease provide details of all discharge points to waters.





Easting (6 digits)

Northing (7 digits)

AMG Zone



Maximum volume to b e discharged during any 24 hour period (kilolitres)

Catchment Name

Name of receiving waters (e.g. Daly River, Rapid Creek)

Type of receiving waters (e.g. open coastal, enclosed, estuarine)

Please ensure that all discharges to water have been included. Attach extra pages if more space is required.



Discharges to LandPlease provide details of all discharges to areas being used for the application of liquid waste, wastewater, effluent or biosolids on, to or into land points to waters.





Easting (6 digits)

Northing (7 digits)

AMG Zone



Maximum volume to be discharged during any 24 hour period (kilolitres)

Catchment Name

Name of nearest waters (e.g. Daly River, Rapid Creek)

Please ensure that all discharges to land have been included. Attach extra pages if more space is required.



9. SUPPORTING DOCUMENTATION

Please ensure that you have attached all the supporting documentation stipulated below for your activity(ies). Refer to the Guide to Environment Protection Approvals and Licences Under the Waste Management and Pollution Control Act for guidance.

Applications will not be processed unless all the appropriate supporting documentation accompanies the application form.

Activity Document Title Tick

A1

Development Consent Permit

Environmental Impact Statement (where applicable)

Location Map in relation to surrounding area and land uses.

Map of site design and layout.

Vehicle Wash Bay Specifications.

Discharge Specifications (if applicable).

Environmental Aspects and Impacts Register.

Procedures for the Management of all Environmental Aspects related to your activity.

Emergency Response Plan that addresses the Environmental Aspects of construction (e.g. spill, fire etc).

Monitoring Plan (Surface Water, Ground Water, Dust, Sediment).

Compliance Plan.

A2









Procedures for how you will dispose of Listed Waste.

Emergency Response Plan that addresses the Environmental Aspects of construction (e.g. spill, fire etc).

Monitoring Plan (Surface Water, Ground Water, Dust and Sediment).

Compliance Plan.

Attachment 1 – as per Section 3 above



A3









Procedures for the storage, recycling and/or treating of Listed Waste.

Facility details for where Listed Waste will be stored (e.g. bunding, ventilation, spill kits etc)

Emergency Response Plan that addresses the Environmental Aspects of operations (e.g. spill, fire etc).

Monitoring Plan (Surface Water, Ground Water, Dust, Sediment and Emissions)

Compliance Plan.

Attachment 1 – as per Section 3 above

A4






Discharge Specifications (if applicable)




Monitoring Plan (Surface Water, Ground Water, Dust, Sediment, Biological and Emissions).

Compliance Plan.



A5





Vehicle Wash bay Specifications.





Monitoring Plan (Surface Water, Ground Water, Dust, Sediment, Biological and Emissions).

Compliance Plan.



10. APPROVAL FEE

The Waste Management and Pollution Control (Administration) Regulations detail the fees for Environment Protection Approvals issued under the Waste Management and Pollution Control Act.

These can be found in the Fees Payable list available on our website www.ntepa.nt.gov.au

Applicants who intend to conduct more than one scheduled activity and/or at multiple premises under the Act are required to pay the sum of all fees due for each activity and premises to which they require an Approval.

Fees are to accompany the Approval application form. Fees can be paid by Credit Card by completing the details below or by Cheque. Cheques are to be made out to the ‘Receiver of Territory Monies’.

Processing will not commence until the correct fee has been received.

CREDIT CARD PAYMENT DETAILS

Card Type NAME ON CREDIT CARD:

CREDIT CARD NUMBER

Card Expiry Date: / Fee Amount to be deducted: $

Cardholder Signature: _______________________________________ Date: / /




11. DECLARATION

This declaration must only be signed by a person(s) with the legal authority to sign it. The ways in which the application may be signed, and the people who may sign the application, are set out in the categories below.

If the proposed licence holder is: Tick The application must be signed and certified by one of the following:

An individual The individual.

A company

The common seal being affixed in accordance with the Corporations Act, or

Two directors, or

A director and a company secretary, or

If a proprietary company that has a sole director who is also the sole company secretary – by that director.

A public authority

The Chief Executive Officer (CEO) of the public authority, or

By a person delegated to sign on the public authority’s behalf in accordance with its legislation (Please note: a copy of the relevant instrument of delegation must be attached to this application).

I/We hereby declare that the information provided in this application and accompanying documents is to the best of my/our knowledge, true and correct.

Signature Signature

Name (printed) Name (printed)

Position Position

Date / / Date / /

Seal (if signing under seal):

Once completed and signed, this form, the application fee and appropriate attachments should be sent to:

Environmental Operations UnitNorthern Territory Environment Protection AuthorityGPO Box 3675DARWIN NT 0801



OFFICE USE ONLY

DATE APPLICATION RECEIVED

INVOICE NUMBER

FEE RECEIVED / /20 RECEIPT NUMBER

APPLICATION APPROVED / NOT APPROVED / /20

NEW APPROVAL OR LICENCE NUMBER EPA



ATTACHMENT 1: LISTED WASTE DETAILSPlease tick the appropriate boxes for the types of listed waste and activities you propose to conduct. You must attach documentation that demonstrates how you handle/manage each type of listed waste and copies of dangerous goods approvals where relevant.

Listed Waste

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Acidic solutions or acids in solid form

Animal effluent and residues

Antimony, antimony compounds

Arsenic, arsenic compounds

Asbestos

Barium compounds other than barium sulphate

Basic solutions or bases in solid form

Beryllium, beryllium compounds

Boron compounds

Cadmium, cadmium compounds

Ceramic-based fibres with physio-chemical characteristics similar to those of asbestos

Chlorates

Chromium compounds that are hexavalent or trivalent

Clinical and related wastes

Cobalt compounds

Containers that are contaminated with residues of a listed waste

Copper compounds

Cyanides (inorganic)

Cyanides (organic)

Encapsulated, chemically fixed, solidified or polymerised wastes

Ethers

Filter cake

Fire debris and fire washwaters

Fly ash

Grease trap waste

Halogenated organic solvents



Listed Waste

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Highly odorous organic chemicals (including mercaptans and acrylates)

Inorganic fluorine compounds excluding calcium fluoride

Inorganic sulfides

Isocyanate compounds

Lead, lead compounds

Mercury, mercury compounds

Metal carbonyls

Nickel compounds

Non-toxic salts

Organic phosphorus compounds

Organic solvents excluding halogenated solvents

Organohalogen compounds that are not otherwise specified in this Schedule

Percholates

Phenols, phenol compounds including chlorophenols

Phosphorus compounds other than mineral phosphates

Polychlorinated dibenzo-furan (any cogener)

Polychlorinated dibenzoo-p-dioxin (any cogener)

Residue from industrial waste treatment or disposal operations

Selenium, selenium compounds

Sewerage sludge and residues including nightsoil and septic tank sludge

Soils contaminated with a listed waste

Surface active agents (surfactants) that contain principally organic constituents and that may contain metals and inorganic materials

Tannery wastes (including leather dust, ash sludges and flours)

Tellurium, tellurium compounds

Thalium, thallium compounds

Triethylamine catalysts for setting foundry sands

Tyres

Vanadium compounds



Listed Waste

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Waste chemical substances arising from research and development or teaching activities, including those substances which are not identified and/or are new and the effects of which on human health and/or the environment are not known

Wastes containing peroxides other than hydrogen peroxide

Waste containing cyanides from heat treatment and tempering operations

Waste from the manufacture, formulation and use of wood preserving chemicals

Waste from the production, formulation and use of biocides and phytopharmaceuticals

Waste from the production, formulation and use of inks, dyes, pigments, paints, lacquers and varnish

Waste from the production, formulation and use of organic solvents

Waste from the production, formulation and use of photographic chemicals and processing materials

Waste from the production, formulation and use of resins, latex, plasticsers, glues and adhesives

Waste from the production and preparation of pharmaceutical products

Waste mineral oils unfit for their original intended use

Waste mixtures, or waste emulsions, of oil and water or hydrocarbon and water

Waste pharmaceuticals, waste drugs and waste medicines

Waste resulting from surface treatment of metals and plastics

Waste tarry residues arising from refining, distillation and any pryolytic treatment

Waste substances and articles containing or contaminated with polychlorinated biphenyls (PCBs), polychlorinated nalthalenes (PCNs), polychlorinated terphenyls (PCTs) and/or polybrominated biphenyls (PBBS)

Waste of an explosive nature not subject to the Dangerous Goods Act

Wool scouring waste

Zinc compounds


applicant details - ntepa.nt.gov.au web viewthe premises are designed to produce more than 500,000...

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