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.
Certificate of Title (e.g. Reference No. / Volume & Folio
and/or Lot on Plan / Diagram No.):
Street Name:
Suburb / Town:
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).
Department of
Environment Regulation
Page 1 of 4
REPORT OF A KNOWN or SUSPECTED
CONTAMINATED SITE
Form 1 [r. 6]
Contaminated Sites Act 2003, section 11
P AR T A ( com pl et e ei t he r P AR T A o r P AR T B o verl e af )
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):
Department of
Environment Regulation
Page 2 of 4
REPORT OF A KNOWN or SUSPECTED
CONTAMINATED SITE
Form 1 [r. 6]
Contaminated Sites Act 2003, section 11
P AR T B ( com pl et e ei t he 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:
Department of
Environment Regulation
Page 3 of 4
REPORT OF A KNOWN or SUSPECTED
CONTAMINATED SITE
Form 1 [r. 6]
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
Address:
Suburb/Town:
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:
Important – make sure you have signed the form and send to:
Manager, Contaminated Sites Branch
Department of Environment Regulation
Locked Bag 33
Cloisters Square
Perth WA 6850
Department of
Environment Regulation
Page 4 of 4