Environmental Protection Authority

FORM

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Form for a request to change implementation conditions under the Environmental Protection Act 1986

Part A: Proponent information and proposal description1. Proponent information

Name of the proponent/s(including Trading Name if relevant)

Australian Company Number(s) ☐ ORAustralian Business Number(s) ☐

Who is referring this request to change implementation conditions?

☐ Proponent☐ Authorised representative (an authorisation from the proponent should be provided).

Name (print) Signature

Position Organisation

Email Phone

Address Street No. Street Name

Suburb State Postcode

Date

Does the referrer request that the EPA treat any part of the proposal information in the referral as confidential?

Provide confidential information in a separate attachment.

☐ Yes ☐ No

Referral declaration for proponent and Authorised representative:

I, ………………………………………………………………, (full name) of………………………………………………………………………. declare that I am authorised to refer this request on behalf of the proponent, and further declare that the information contained in this form is true and not misleading.

Note: If the referrer is responsible for the proposal but is not the nominated proponent, then an Instructions to change nominated proponent form must be submitted with this Form.

Provide contact details for purposes of the assessment, if different from the above. Include: name, physical address, phone, email.

2. Pre-referral discussions

Identify outcomes of any pre-referral discussions with EPA Services

Published April 2018

3. Proposal information

Title of the proposal

Ministerial Statement Number/s

Proposal description

Previous changes to the proposal

Is this a revised proposal?

4. Type of change to conditions request

Tick all that apply: Change to implementation conditions (section 46)

Change or variation of conditions Removal of conditions Extension of Time Limit of Authorisation for Proposal Implementation Statement consolidation or amalgamation

Change to proposal* and change to conditions (section 45C + section 46) – a change to proposal request should also be submitted

Interim conditions and procedures (section 46A) Minor changes to conditions (section 46C)

* See Change to proposal request

☐☐☐☐☐☐☐

5. Summary of proposed changes to conditions

Provide a brief summary of proposed changes, reasons for the changes, and non-compliances.

Part B: Environmental assessment 1. Identification of existing conditions to be changed (complete for each change)

Condition number and title

Explain the intent of the existing condition

EPA Factor and Objective of existing condition

New EPA Factor and Objective

2. Proposed changes to conditions

Define the proposed change to condition and wording of new proposed condition

Relevant EPA Factor and Objective

Relevant EPA Policy and Guidelines applied

Identify changes to Schedule 1

Environmental Studies/Supporting Information. Provision of IBSA data package.

Consultation conducted (include discussions relating to changes to licences/permits)

Changes to Environmental Management Plans

Provision of spatial information

Published April 2018