REPORT of a KNOWN Or SUSPECTED CONTAMINATED SITE

REPORT OF A KNOWN or SUSPECTED CONTAMINATED SITE Form 1 [r. 6]

Contaminated Sites Act 2003, section 11 PERSON REPORTING THE SITE: Family Name: Given Name(s): Company (if applicable):

Postal Address: Suburb/Town:

Postcode: Phone: Fax: Email: Are you:

Relationship with the site:

SITE DETAILS / DESCRIPTION OF LAND TO WHICH REPORT RELATES (if possible, include a map to identify site)

Lot No. and/or Street No. Street Name: Certificate of Title (e.g. Reference No. / Volume & Folio Suburb / Town: and/or Lot on Plan / Diagram No.): Postcode: (incl. copy of current Certificate of Title)* Local Government:

*Not required unless this form is submitted by a person under a duty to report the site under the Contaminated Sites Act 2003 section 11(4).

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Contaminated Sites Act 2003, section 11

P AR T A ( c o m p l e t e e i t h e r P AR T A o r P AR T B o ve r l e a f )

SUSPECTED CONTAMINATION: Date on which you first suspected that the site was contaminated: Type of contamination you suspect: Suspected source of contamination:

Where is the suspected contamination? (i.e. soil, groundwater, surface water): Reason(s) why contamination is suspected:

Previous activity, or activities and/or land use, or uses (if known): Current activity, or activities and/or land use, or uses (if known): Future activity, or activities and/or land use, or uses (if known):

Is a licence under the Environmental Protection Act 1986 Part V in force, or ever been in force, in respect of any part of the site?

Licence No. (if known): REPORT OF A KNOWN or SUSPECTED CONTAMINATED SITE Form 1 [r. 6]

Contaminated Sites Act 2003, section 11

P AR T B ( c o m p l e t e e i t h e r P AR T A o r P AR T B )

KNOWN CONTAMINATION: Date on which you first knew that the site was contaminated: Known contaminant(s): Suspected source of contamination: Where is the contamination? (i.e. soil, groundwater, surface water): Previous activity, or activities and/or land use, or uses (if known): Current activity, or activities and/or land use, or uses (if known): Future activity, or activities and/or land use, or uses (if known):

Is a licence under the Environmental Protection Act 1986 Part V in force, or ever been in force, in respect of any part of the site?

Licence No. (if known): Details of investigations undertaken to confirm the presence of contamination (where investigations have been reported, list report title, author and date, and attach copies to this form):

Details of any remediation undertaken or planned:

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Contaminated Sites Act 2003, section 11 Note that under the Contaminated Sites Act 2003, it is an offence to: Report a site maliciously and without reasonable grounds to believe or suspect that the site is contaminated (section 11(9)); or Make a statement in this report which you know is false or misleading in a material particular (section 94); or Make a statement, in making this report, which is false or misleading in a material particular, with reckless disregard as to whether the statement is false or misleading in a material particular (section 94); or Provide, or cause to be provided, in making this report, information that you know is false or misleading in a material particular (section 94); or Provide, or cause to be provided, in making this report, information that is false or misleading in a material particular, with reckless disregard as to whether or not the information is false or misleading in a material particular (section 94); or Fail to disclose, or cause a failure to disclose all information which you know is materially relevant in making this report (section 94).

IF THIS REPORT IS BEING MADE BY AN INDIVIDUAL: Signature of person making the report : Date: Title & Full Name: Postal Suburb/Town: Address: Postcode: Phone: Fax: Email:

IF THIS REPORT IS BEING MADE BY A BODY CORPORATE, IT MAY BE SIGNED ON BEHALF OF THE BODY CORPORATE BY AN AUTHORISED OFFICER AND NEED NOT BE MADE UNDER ITS SEAL: I, (Position)

am authorised by [ ] to make this report on behalf of that body corporate. (Body Corporate name)

Signature: Date: Title & Full Name: Postal Address: Suburb/Town: Postcode: Phone: Fax: Email:

I m p o r t a n t – m a k e s u r e yo u h a ve s i g n e d t h e f o r m a n d s e n d t o : Manager, Contaminated Sites Branch Department of Water and Environmental Regulation Locked Bag 33 Cloisters Square Perth WA 6850