Application form: Replacement of licence Part V, Division 3, Environmental Protection Act 1986

Environmental Protection Regulations 1987

Part 1: Application type

INSTRUCTIONS:

• Completion of this form Is a statutory requirement under section 57(1)(a) of the Environmental Protection Act 1986 (WA) (EP Act) to apply for a licence. This form may be used to apply for a new licence to replace a licence which has previously ceased to have effect due to non-payment of fees In accordance with regulation 5DA(5) of the Environmental Protection Regulations 1987 (EP Regulations}.

• This form may only be used to apply for a replacement licence where no materla! changes have been made to lhe premises since the date that the licence was last issued or amended, and no changes are proposed as part of the applicatron.

• The instructions set out in this application form are general in nature.

A reference to 'you' in these instructions is a reference to the applicant.

The information provided to you by DWER in relation to making applications does not constitute legal advice. DWER recommends that you obtain independent legal advice.

Applicants seeking further information relating to requirements under the EP Act and/or EP Ri,gulations are directed to the State Law Publisher website {www.slp.wa.gov.au).

• The applicaflon form must be completed with all rel avant information attached. If there is insufficient space on any part of this form, please continue on a separate sheet of paper and attach to this form. If an application form has been submitted which is incomplete or materially incorrect, the CEO will decline to deal with the application and advise the applicant accordingly.

11 Licence Number:

1.2

1.3

Date that the licence was last issued / amended:

Insert the date of issue, or the date of the last amendment, whichever is the most recent.

Tick the box to confirm that since the date listed In 1.2 above, no material changes been made to the premises; infrastructure within the premises; and/or activities undertaken at the premises.

oa BEP 2016

IR-F16 Application Form- Replacement of licence (V1, January 2018) 1

Part 2: Applicant details

INSTRUCTIONS:

The applicant (the occupier of the premises) must be an individual(s), a company, body corporate, or public authority, but not a partnership, trust, or Joint-venture name. Applications made by or on behalf of business names or unincorporated associations will not be accepted.

If applying as an individual, your full legal name must be inserted.

• If applying as a company, body corporate, or public authority, the full legal entity name must be inserted.

Australian Company Number's (ACN) must be provided for all companies or body corporates.

Details for a contact person must be provided for DWER enquiries in relation to your application. This contact person can be a consultant if authorised lo represent rhe applicant. Proof of authorisation will be required.

• All written correspondence from DWER regarding your application will be made via email; you must provide a va!id email address through which you agree to accept all electronic correspondence. Statutory notices will be posted to your postal address.'

• Companies or body corporates making an application must nominate an authorised representative from within their organisation. Proof of authorisation will be required.

2.1

2.2

Applicant name jfull legal name/s):

[the propo;,ed holder of the works approval, licence or registration]

ACN (if applicable):

Trading as (if applicable):

2.3 Authorised representative details:

[the person authoriS€d to receive

Name

correspondence and notices Position under the EP Act - all correspondence will be sent to , this email address apart from : Telephone

CH l TTE CL.I NG.

statutory notices which will be f----------- ---------------------J

served to the address specified Email in 2.4 below]

2.4 Address for notices to be served under the EP Act:

2.5

[this must be a physical address to which a statutory notice under the EP Act may be delivered] (see below, footnote 1)

Contact person details for Name DWER inquiries relating to the f------------------------------1 application (if different from the authorised ropmsentative ):

[for example, could be a consultant or a srte-based employee]

1 Position '

I

Organisation (if different to applicant}

Address (if different from above)

Telephorle

I .Email

1 T"le provision of a postal/business address is also reqt:ired, as any statutory notices or direction under the rEievant legisiation are required to be served by post O' personalty [sections 75 arid 76 Interpretation Act 1984 (WA)].

IR-F16 Application Form - Replacement of licence (v1, January 2018) 2

Part 3: Premises details

3.1

3.2

3.3

Premises legal description (whole or part to be specified):

[Include the land description (volume andfolio number, lot or location numberfs); Crown lease or reserve number; pastoral lease number, or mining tenement number (as appropnate), of all properties. as shown on title details registered with Landgate.

Also include the street address]

Premises name (if applicable):

Local Government Authority area:

[City, Town or Shire]

GPS or map coordinates:

[GPS coordinates (latitude and longitude) must be provided where cadastre or mining tenements are not used as the premises boundary]

I

I

LOT lo\ 01--J D\AGQ..o..(Y) 4t.S71

N\l ~Q~y Q...Of:\~,

\"l'.OOL/A8€.Ef'..lf:E. WC\ Co~

B,l~t::ac:)I'-' u~,•~C>~l(._L 12...£(._"'t Cl i NG..

I 1-------------------------'---- ------···-·-··------~-----l Attachments Yes >------------~-------- --- - --'--------------+-----!

3.4

3.5

Attachment 1: Access to land

Attachment 2; Premises mapls

A copy of the certificate of title, pastoral lease, or mining tenement, as applicable, must be attached to this application form labelled Attachment 1.

An aerial photograph, map and site plan of the premises must be included as an attachment to this appl1cation form labelled Attachment 2.

You must provide an aerial photograph of sufficient scale showing the Prescribed premises

You must also provide a map or maps of the prescribed premises. 1dentify1ng:

• layout of key infrastructure and buildings, clearly labelled:

• the premises boundary:

• emission and discharge points (with GPS coordinates where available);

• sensitive receptors and land uses, and

• all areas proposed to be cleared Of applicable),

Maps must contain a north arrow, clearly marking the area in which the activities are earned out The map or maps must be of reasonable clarity and have a visible scale.

IR-F16 Application Form - Replacement of licence (v1 , January 2018) 3

Part 4: Proposed Fee Calc ulation

INSTRUCTIONS:

Applications for a licence require the payment of the prescribed fee in accordance with regulation 5D of the EP Regulations.

Fee calculators are available online to assist in completing this sectlon atwww.der.wa.gov.;1ulLicenceFeeCa!cu1ator.

• Different fee units apply for different fQe compommts. Fee units may also have different amounts depending on the period in which the calculation is made.

4.1 I All information and data used for the calculation of proposed fees has been provided in · accordance with section 4.3.

r--=--=---.,_.---,,---,---,---~--- --- ------- ---=--=,-:-::-....,.,.,,.,...-,,=-:,,,_ _______ .....,,,,,..._~ 4 2 Detailed licence fee calculatlcms ---- -

Part 1 Premises component (see regulator. 50 and Part 1 of Schedule 4 of the EP Regulations)

Toe production or design capacity should be the max1mum capacity of the premises. For most categories the production or deslgn capacity refers to an annua! rate. The figure shculd be based on 24 hour operation for 365 days, unless there is another reg ulatcry approval or technical reason that restricts operation.

The premises component fee applies to the category in Part 1, Schedule 4 of the EP Regulations incurring the higher or highest amount of fee units in accordance with regulation 50(2) of the EP Regulations.

List all categories and their fee units (insert additional rows as required). Use only the higher or highest amount of fee units to determine the Part 1 fee component

............... -~~-- • • ,..-• -<v••-~• -

j Category Productro~ or design capacity Fee units

l b~ (LA$'S :!L 20-'::000 -ro,~..:'.)(Sj '-I~ 2-4

I Using higher or highest amount of fee urnts, Part 1 component subtotal $

Part 2 Waste (see regulation 5D(1 a)(b) and Part 2 of Schedule 4 cf the EP Regulations)

II Jf your premises includes one or more of the following categories specify any applicable Part 2 waste amounts. Do , not include Part 3 waste components of these discharges in the below sections.

I

i Categories: 5, 6. 7, 8, 9, 12, 14, 44, 46, 53, 54A, 70, 80, or 858

Part' 2 waste means waste consisting of -

. ( ) t T a a11ngs'. or

(b) bitterns; or

(c) water to allow mining of ore, or

(d) flyash; or

(e) waste water from a desalfnation plant.

If your premises does not falf into one of the categories listed above, or there are no applicable Part 2 waste amounts, the sub total for this section will be $0.

Insert additional rows as requfred. Sum all Part 2 waste fees to determine the sub total. _ ..,, .. _ ... ...., ... ~

Discharge quantity (to~mes/year) Fee units

Part 2 component subtotal $ .

I R-F16 Application Form - Replacement of licence (v1 . January 2018)

;

·--~~

I

4

Part 4: Proposed Fee Calculation

Part 3 Waste - Discharges t0 air, onto land, into waters (see Part 3 of Schedule 4 of the Environmental Protection Regulations 1987)

Choose the appropriate location of the discharge and enter the discharge amount(s) in the units speafied in the EP Regulations. This should be the amount of waste expected to be discharged over the next 12 months, expressed in the un,ts and averaging period applicable for that waste kind (for example, g/minute or kg/day). Amounts can be measured, calculated. or estimated and can be based on data acquired over the previous 12 months, but should be based on the maximum premises capacity and not the forecast operating hours.

Where there are discharges, all prescribed waste types must be considered in the fee calculation If a specified waste type is not present in the discharge, this must be justified using an appropriate emission estimation technfque (for example, sampling data, industry sector guidance notes, National Pollution Inventory guides and emission factors).

Discharges to air - -----~~ - -" - - -

· Discharges to air Discharge rate Discharges to air D1scbarge rate (g/minj (gfmin)

-- --- -

Carbon monoX1de NIL Nickel I NIL I

Oxides of nitrogen I NIL Vanadium

I l'-J IL I

' Sulphur oxides NIL Zinc N\L I

Particulates (Total PM) l\J IL Vinyl chloride NIL ~-··~--

Volatile organic compounds NIL Hydrogen sulphide N\ L.

Inorganic fluonde I N1L Benzene NIL Pesticides

I N\L Carbon oxysulph1de N\L

Aluminium N\L Carbon disulphide NIL-

Arsenic NIL Acrylates I f'Jl L

I

I I

Chromium N,L Beryllium "-I\ L I

I

I Cobalt N\L Cadmium NiL

Copper NlL Mercury I NIL

Lead TDI (toluene-2, I

N\L 4-di~iso-cyanate) N'L

Manganese N'L

MDI (diphenyl-methane N\L di-iso-cyanate)

Molybdenum JI..)\ L- Other waste i N\L

Part 3 component subtotal so Discharges onto land <:>r Into waters Discharge rate

-1. Liquid waste that can potentially deprive (a) biochemical oxygen demand (in

receiving waters of oxygen (for each the absence of chemical oxygen NIL kilogram discharged per day)- demand limit)

(b) chemical oxygen demand (in the absence of total organic N\L carbon !im,t)

(c} total organic carbon N\L

IR-F16 Application Form - Replacement of licence (v1, January 2018) 5

Part 4: Proposed Fee Calculation

I

2 Biostim:;lants (for each kilogram discharged (a) phosphorus t-J 1~ per day)-

(b) total nitrogen N\l-

3. Liquid waste that physically alters the (a) !otal suspended solids (for each N\L

characteristics of naturally occurring kiiograrr. dlscharged per day} i waters - (b) surfactants (for each kilogram NI L dlscharged per day)

(c) colour alteration (for each

' platinum cobalt u:1it of colour I

above the ambient colour of the N \ L. waters ln each megalitre discharged per day)

(d) temperature alteration (for each 1 ~c above the aMbient tern perat:.ire of the waters in each megal1tre discharged per N\ L--day)-{i) in the sea south of the Tropic

t of Capricorn (~) in other waters

4, Waste that can poteribally accumulate in the (a) aluminium I

1'.J \ L environmer.t or living tissue (for each ;

kilogram discharged per day) -(b) arsenic N\L I ! -

I (c) cadmium

' N\L I

(d) chromium t-J \L (e) cobalt N\L

I (f) copper N\L I (g) lead Nti..-I

(h) mercury N i L-!

(i) molybdenum i'-J \ l.,.. I 0) nickel NiL

' i

(k) vanadium "-\ \ L

(I) zinc f\,ii L I

I (m) pest1c1des

NI L I

(n) fish tainting wastes I Nll-

(oj manganese ! N\I ...

i

5 E coli bacteria as indicator species '(in each (a) 1.000 to 5,000 organisms per I N\L

megalltre discharged per day)- 10C ml i {b) 5,000 to 20,000 organisms per

N\L 100 ml :

i 'I (C) more than 20,000 organisms NI L-per 100 ml

I R-F16 Application Forni - Replacement of licence (v1 , January 2018) 6

Part 4: Proposed Fee Calculation

6. Other waste (per kilogram discharged per (a) oll and grease Nh ... day)-

{b) total dissolved solrds NIL-

{c) fluoride I

NIL-

(d) iron I Nil-

(e) total residual chlorine NIL

{f) other t--1 i I.-

Part 3 component subtotal $0 ..

. Summary- Proposed licencl'! fee I~--'-••• ---·---·-· ··--·-

Part 1 Component $ ----

Part 2 Component $ ..

Part 3 Component $

- ··-····-- ------.--

Total proposed lroouce fees. $ r--:-_------------------- - - - --··

4.3 lnformatlcm and Data Used to Calculate Proposed Fees

The detailed calcu/at1ons of fee components, including all Information and data used for the calculations are to be provided as attachments to this application, labelled as Attachment 3, with an appropriate suffix (for example 3A, 38 etc). Please specify the relevant attachment number in the spacets provided below.

4 4 Proposed fee for licence Attachment No - -·-· -------

Part 1 • Premises NA Part 2 Waste types Nt)..

Part 3: Discharges to air, onto land, into waters ~ti,.

~ ·-----'

Part 5. Subm ission of Application r-NOTE:

Information submitted as part of this application may be made publicly available. If you wish to submit infonnation that you believe to be commercially sensitive or otherwise confidential, then you should submit that information in an attachment to this application labelled Attachment 4 with a written statement of reasons why you request that each item of information be kept confidential DWER wlll take reasonable steps to protect genuinely confidential or commercially sensitive information. Please note in particular that au submitted information may be the subject of an application for release under the Freedom of lnfonnation Act 1992.

All information which you would propose to be exempt from public disclosure has been separately placed in Attachment 4 (located at the end of this form) Grounds for claiming exemption m accordance with Schedule • 1 to the Freedom of Information Act 1992 have been specified.

A full, signed, electronic copy of this form has been submitted via in:foa'l>dwttJ:.~ gov.§u ~

OR

A full, signed, hard copy of this form has been sent to·

APPLICATION SUBMISSIONS ~ Department of Water and Environmental Regulation Locked Bag 33 Cloisters Square PERTH WA 6850

IR-F16 Application Form - Replacement of licence (v1, January 2018) 7

Part 6: Declaration and signature

General

//We confirm and acknowledge lhat

• the Jn:ormation contair:ed in this application is true and correct and 1/vve acknowledge that knowingly providing information v-Jhich is false or misleading :n a maiEr.ai particular cons~tJtes an offence under section 112 oft'le Environmental Protection Act 1986 ~A) and may incur a penalty of up to $50_000,

• IM/e have legal aulhority to sign on behalf of the applicant (where a:.ithorisatlon provided);

• IM/e have not altered the requ1rements a:-:d instr ... ct:ons set out 1n th;s app!icatior. form;

• IM/e have provided a vahd email address in Part 2.3 for receipt of all wrif.en .correspondence from DWER in reiation to ttl:s applicatio:-:. INVe acknowledge that successful delivery xi my/our seNer constirutes receipt of correspondence for the purposes of the EP Act: and

• I/We have provided a va!id postal and /or business address in Part 2A for the service of all statutory notices under lhe relevant leglslation.

Publication

IM/e confirm and acknowledge·

• this applicabon (including all attachments, apart from the sections identified in Attachment 4) is a pubfic doeument and may be pub.l1shed;

• all necessaiy consents for the publication of !nformation have been obtained from third parties:

• information considered exempt from public disclosure has been placed in Attachment 4 with reasons as to why the information shouid be exempt in accordance with the grounds specified 1n Schedule 1 to the Freedom of lnfonnation Act 1992 0,NA);

• subsequent ;nfurmation provided m relation to this application will be a pubnc document and may be published unless wntten notice has been given to the Department by the appiicant, at the time the information is provided, claiming that the information is considered exempt frcm public disclosure; and

• the decision to not pub!ish information will be at the d1sC1efi0n of the CEO of the Department and will be made consisten~ywith the prov.sions of the Freedom offnformation Act 1992 0NA).

NOTE: This form may be signed: if the applicant is an individual, by the individual; if the appllcant Is a corporation, by: • the common seal being affixed in accordance with the Corporations Act 2()()1; or • two directors; or • a director and a company secretary; or • if a proprietary company has a sole director who Is also the sole company secretary, by that director; and by a psrson with IGgal authority to sign on behalf of the applicant.

IR-F16 Application Form - Replacement of licence (v1, January 2018) 8

Attachment 4 : Request for Exemption from Publication

Information which you consider should not be published. on the grounds of a relevant exemption found in Schedule 1 to the Freedom of lnfonnation Act 1992, must be specified in this Attachment

NOT FOR PUBLICATION IF GROUNDS FOR EXEMPTION ARE DETERMINED

Section [xJ: Ground for claiming exemption:

Section [x] Ground for claiming exemption:

I R-F16 Application Form - Replacement of licence (v1, January 2018) 9

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Application B559366

Volume 1423 Folio 433 WESTERN A AUSTRALIA

CERTIFICATE OF TITLE UNDER THE "TRANSFER OF LAND ACT, 1893" AS AMENDED

LT. 38

REGISTER BOOK

VOL. FOL.

1509 766

I certffy that the person described in the First Sr;hedule hereto is the registered proprietor of the undermentioned estate In the undermentioned land subject to the easements and encumbrances shown ln the Second Schedule hereto.

~ Dated 20th July, 1978 REGISTRAR OF TITLES

ESTATE AND LAND REFERBED TO

NOTE: RULING THROUGH AND SEALING·WITH THE OFF.ICE SEAL INDICATES THAT AN ENTRY NO LONGER HAS EFFECT. ENTRIES NOT RULED THROUGH MAY BE AFFECTED BY SUBSEQUENT ENDORSEMENTS.

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FIRST SCHEDULE (continued)

SECOND SCHEDULE (continued)

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