SCHEDULE : PERMIT ACTIVITY REPORT FORM

Department of Primary Industries, Parks, Water and Environment Policy and Conservation Assessment Branch

Permit number Permit expiry date

Permit holder details:

Surname Given name/s Title

Business/Organisation name

Phone number/s Email

Location of ‘take’ (Address and PID or Land Title Number)

Signature of permit holder Date (or approved delegate)

Please ensure you have completed the impact table overleaf before submitting

Completed forms can be faxed, e-mailed or posted to: Conservation Assessment Section, Resource Management and Conservation Division Department of Primary Industries, Parks, Water and Environment, GPO Box 44 Hobart, TAS 7001 [email protected] Phone 03 6165 4381 Fax 03 6223 8603 1. Personal information will be collected from you for the purpose of managing Tasmania’s natural values and will be used by DPIPWE for assessing, considering, advising upon, managing and/or determining the relevant application and may be used for other purposes permitted by the Crown Lands Act 1976, National Parks and Reserves Management Act 2002, Nature Conservation Act 2002, Threatened Species Protection Act 1995 and Wellington Park Act 1993 and regulations made under these Acts. 2. You are required to provide this information by the Crown Lands Act 1976, National Parks and Reserves Management Act 2002, Nature Conservation Act 2002, Threatened Species Protection Act 1995 and Wellington Park Act 1993 and regulations made under these Acts. Completing this form is a permit requirement. 3. Your basic personal information may be disclosed to other public sector bodies where necessary, for the efficient storage and use of the information

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4. Personal information will be managed in accordance with the Personal Information Protection Act 2004 and may be accessed by the individual to whom it relates on request to DPIPWE. Impact table

Species scientific name Date(s) Number or Area of GPS GPS GPS Impact type Any additional of ‘take’ estimate population Easting Northing position (e.g. information (including taken (in m2) (GDA 94 (GDA 94 accuracy vegetation (e.g. likelihood +/- range) of format) format) (in m) clearance, of survival of individuals burning) specimens taken taken)

Any other comments

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