<p> Application form</p><p>Environmental Protection Regulation 2008</p><p>Exemption for transport of trackable waste This form is to be used to submit an application for exemption for transport of trackable waste, under section 81Y of the Environmental Protection Regulation 2008. Approvals must be granted before you can proceed lawfully with your project and any associated activities. Please read the information sheets and any guidelines included with your application kit to understand the environmental management and conservation issues, policies and procedures that relate to the activities proposed.</p><p>1. Applicant name/contact person</p><p>Name</p><p>1. 2. Trading as</p><p>Name </p><p>3. ACN/ARBN</p><p>ACN/ARBN </p><p>All bodies registered under Corporations Law will have an Australian Company Number (ACN), except for some foreign bodies which will have an Australian Registered Body Number (ARBN).</p><p>4. Applicant address and contact details</p><p>Street address/registered office </p><p>Telephone Fax/mobile</p><p>Email</p><p>Page 1 of 3 • 140917 • EM1991 • Version 3 ABN 46 640 294 485 Application form Exemption for transport for trackable waste</p><p>5. Specific information requirements 5.1 Name and type of waste</p><p>5.2 Provide information to satisfy the administrating authority that the waste does not show any environmentally significant characteristics?</p><p>5.3 You are required to provide a report of initial assessment with this application. Please tick the boxes below to show you have included the information requested.</p><p>Use the checklist as a guide to having attached all essential information in your application. Applicants should read carefully the information sheet Exemption of trackable waste. Type of waste Type of contaminant(s) Sampling and analysis program to determine properties and concentration Justification for sampling frequency Level/concentration of contaminant(s) NATA registered laboratory Whether the waste is a dangerous good Review of results against Schedule 2G of the Environmental Protection Regulation 2008</p><p>Page 2 of 3 • 140917 • EM1991 • Version 3 Department of Environment and Heritage Protection Application form Exemption for transport for trackable waste</p><p>6. Declaration</p><p>Read carefully through the certification before signing. Note that the ‘responsible person’ or their appointed signatory must sign this form.  I do solemnly and sincerely declare that the information provided is true and correct to the best of my knowledge and I make this solemn declaration conscientiously believing the same to be true and by virtue of the provision of the Oaths Act 1867.  I am aware that it is an offence under section 480 of the Environmental Protection Act 1994, to give the administering authority a document containing information that I know is false or misleading in a material particular.  I understand that all information supplied on or with this application form may be disclosed publicly in accordance with the Right to Information Act 2009 and the Evidence Act 1977.</p><p>APPLICANT’S NAME PRINT NAME OF APPOINTED SIGNATORY (IF APPLICABLE)</p><p>APPLICANT’S SIGNATURE/APPOINTED SIGNATORY’S SIGNATURE DATE</p><p>7. Applicant checklist Please return your completed application kit to:</p><p>Application form(s) completed and signed Trackable Waste Regulation and Support Department of Environment and Heritage Protection Permit fees paid or enclosed GPO Box 2454 Supporting information and accreditation Brisbane Queensland 4001 attached Enquiries: (07) 3330 5677 Facsimile: (07) 3330 5634 Email: [email protected]</p><p>Page 3 of 3 • 140917 • EM1991 • Version 3 Department of Environment and Heritage Protection</p>