Application form:
works approval / licence
Division 3, Part V, Environmental Protection Act 1986 (EP Act)
Environmental Protection Regulations 1987
(EP Regulations)
To the Chief Executive Officer
This is an application for
[select only one option]
☐ Works approval
☐ Concurrent works approval and licence
☐ Licence (works approval already obtained)
Works approval number: [______]
☐ Renewal
Licence or works approval number: [______]
☐ Amendment
Licence or works approval number: [______]
This application is for the
category/categories of
prescribed premises
☐ Single category of prescribed premises
(specify category number): _______________________
☐ Multiple categories of prescribed premises
(specify category numbers): _______________________
☐ All activities on the premises within category of prescribed
premises of Schedule 1 to the EP Regulations have been
specified above (tick if Yes)
Part 1. Applicant details
1.1
Applicant name
(full legal name)
ACN number
1.2
Directors details
(if applicant is a
corporation)
1.3
Registered business
address
1.4
Address for
correspondence
Application form: Works approval or licence (draft released for consultation)
Department of Environment Regulation
1.5
Contact person details
Name
Position
Telephone
Email
1.6
Authorised
representative
(if any)
Name
Telephone
Email
1.7
1.8
Occupier status
Proof of occupier status
Registered proprietor on certificate of title
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Lease holder (please specify)
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Public authority that has care, control or management
of the land
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Other (please specify)
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Attachment 1 completed
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Attachment 2 completed
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Attachment 3 completed
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Part 2. Premises
2.1
Premises legal
description
Land description:
volume and folio
number, lot or location
number(s), Crown
lease or reserve
number, pastoral lease
number or mining
tenement number of all
properties
2.2
Local government area
2.3
An aerial photograph
and map of premises
2.4
GIS coordinates
(if required)
Part 3. Proposed activities
3.1
Description/overview
provided
3.2
Estimated operating period (based on estimated infrastructure life)
Application form: Works approval or licence (draft released for consultation)
years
2
Department of Environment Regulation
Part 4. Other approvals
No
Yes
4.1
Is the proposal a Major Resource Project (formerly known as a State
Development Project?
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4.2
Has the proposal been referred to the Environmental Protection Authority?
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4.3
Is the proposal subject to any Ministerial conditions under the EP Act?
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4.4
Has the proposal been referred or assessed under the Environment
Protection and Biodiversity Conservation Act 1999 (Commonwealth)?
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4.5
Has the proposal obtained all relevant planning approvals?
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4.6
Has the proposal obtained all other necessary statutory approvals?
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Attachment 4 completed
Part 5. Fit and competent operator
No
Yes
5.1
Has the applicant ever been convicted of an offence under the EP Act or
its subsidiary legislation or similar legislation in Australia?
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5.2
Has the applicant been issued with one or more penalty infringement
notices or compliance orders under the EP Act or its subsidiary legislation?
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5.3
Has the applicant ever breached any conditions of licence or works
approval under the EP Act or its subsidiary legislation?
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5.4
Has the applicant ever had an equivalent works approval or licence from
this State or elsewhere that was suspended and/or cancelled?
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5.5
Does the applicant have previous experience, or are there key personnel
with previous experience, in relation to activities in the proposal?
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If Yes to any of the above, Attachment 5 completed 
Note: For an applicant that is a company, each director must complete this
section as individual, and include their previous history as directors of other
companies.
☐
Part 6. Public health and environmental risks
6.1
Are there emissions to air from the activities that pose a risk to public
health or the environment?
(includes emissions from stacks, chimneys, baghouses, tank vents or blow
offs, dust, noise and odour emissions)
Application form: Works approval or licence (draft released for consultation)
No
Yes
☐
☐
3
Department of Environment Regulation
6.2
Are there emissions to surface water from the activities that pose a risk
to public health or the environment?
(includes end of pipe or outfall emissions to river, lakes, estuary or seas
and contamination from containment leakage)
6.3
Is there a risk of other incidents arising from the activities that pose a risk
to public health or the environment?
(includes risk of a pollution incident or unplanned event related to
hazardous materials or dangerous goods stored, used or handled)
6.5
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Are there emissions to land from the activities that pose a risk to public
health or the environment?
(includes point source emissions to groundwater including direct aquifer
reinjection, as well as emissions to land through irrigation, infiltration and
seepage pits and contamination from containment leakage)
6.4
☐
Is there waste accepted or stored on the premises?
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Attachment 6 completed
Part 7. Siting and location
No
Yes
7.1
Are there premises located within specified separation distances for
sensitive receptors?
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7.2
Are the premises located within or adjacent to any sensitive surface water,
groundwater or terrestrial areas?
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Attachment 7 completed
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Part 8. Assessment Framework
8.1
All modelling information required under the Assessment Framework provided.
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8.2
All monitoring information required under the Assessment Framework provided.
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8.3
Compliance with relevant environmental standard or supporting information for
variation from environmental standard.
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Attachment 8 completed
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Part 9. Submission of proposed fee calculation
All information and data used for the calculation of proposed fees provided.
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Attachment 9 completed
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Application form: Works approval or licence (draft released for consultation)
4
Department of Environment Regulation
Part 10. Submission of application
All information considered exempt from public disclosure has been separately placed in
Attachment 10. Grounds for claiming exemption in accordance with Schedule 1 to the
Freedom of Information Act 1992 must be specified.
☐
A full electronic copy has been submitted via info@der.wa.gov.au
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A full hard copy has been sent to:
APPLICATION SUBMISSIONS
Department of Environment Regulation
Locked Bag 33 Cloisters Square
PERTH WA 6850
☐
Acknowledgement and signature
To the Chief Executive Officer:
I,
(name)
(position)
I confirm I am authorised on behalf of the applicant to submit this application.
I confirm that the information contained in this application is true and correct and I acknowledge
that knowingly providing information which is false or misleading in a material particular commits
an offence under section 112 of the Environmental Protection Act 1986 and may incur a penalty
of up to $50,000.
I acknowledge that this application (excluding Appendix 10) is a public document and may be
published. I confirm that information considered exempt from public disclosure has been placed
in Appendix 10 with reasons as to why the information should be exempt in accordance with the
grounds specified in Schedule 1 to the Freedom of Information Act 1992.
I acknowledge that the decision to not publish information will be at the discretion of the
Department of Environmental Regulation and will be made consistently with the provisions of the
Freedom of Information Act 1992.
________________________________
(Signature)
Date
Application form: Works approval or licence (draft released for consultation)
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Department of Environment Regulation
Attachment 1: Proof of occupier status
Application form: Works approval or licence (draft released for consultation)
6
Department of Environment Regulation
Attachment 2: Map for proposed premises
Application form: Works approval or licence (draft released for consultation)
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Department of Environment Regulation
Attachment 3: Proposed activities
Application form: Works approval or licence (draft released for consultation)
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Department of Environment Regulation
Attachment 4: Other approvals
Application form: Works approval or licence (draft released for consultation)
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Department of Environment Regulation
Attachment 5: Fit and competent operator
Application form: Works approval or licence (draft released for consultation)
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Department of Environment Regulation
Attachment 6: Public health and environment risks
Potential risk source
1
Emissions to air
2
Emissions to water
3
Emissions to land
Waste type
Specific emission
(type and quantity)
Receptor and
proximity
Proposed control
Quantity
Storage
Location
Application form: Works approval or licence (draft released for consultation)
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Department of Environment Regulation
Attachment 7: Siting and location
Application form: Works approval or licence (draft released for consultation)
12
Department of Environment Regulation
Attachment 8: Assessment Framework
Information required in Assessment Framework
Application form: Works approval or licence (draft released for consultation)
Annexure number
13
Department of Environment Regulation
Attachment 9: Proposed fee calculation
Summary of proposed fees
Proposed works approval fee (see Schedule 3 of the EP Regulations)
Fee component
Proposed fee
Cost of works: $
$
Proposed licence fee (see Schedule 4 of the EP Regulations)
Part 1 Component
Part 2 Component
Part 3 Component
Total proposed licence fees:
Note:
$
(1)
DER has a fee calculator available on its website.
(2)
Different fee units apply for different fee components. Fee units may also have
different amounts depending on the period in which the calculation is made.
Detailed breakdown of proposed licence fees
Premises component
Proposed licence fee: Part 1 Premises (see Part 1 of Schedule 4 of the EP Regulations)
Premises:
Sub total
$
Discharges to air, onto land, into waters
Proposed licence fee: Part 3 Discharges to air
(see Part 3 of Schedule 4 of the EP Regulations)
Discharges to air
Discharge
quantity
Discharges to air
Carbon monoxide
Nickel
Oxides of nitrogen
Vanadium
Sulphur oxides
Zinc
Particulates
Vinyl chloride
Volatile organic
compounds
Hydrogen sulphide
Inorganic fluoride
Benzene carbon oxysulphide
Application form: Works approval or licence (draft released for consultation)
Discharge
quantity
14
Department of Environment Regulation
Aluminium
Carbon disulphide
Arsenic
Acrylates
Chromium
Beryllium
Cobalt
Cadmium
Copper
Mercury
Lead
TDI (toluene-2,
4-di-iso-cyanate)
Manganese
MDI (diphenyl-methane
di-iso-cyanate)
Molybdenum
Other waste
Subtotal
$
Proposed licence fee: Part 3 Discharges onto land or into waters
(see Part 3 of Schedule 4 of the EP Regulations)
Discharge
quantity
Discharges onto land or into waters
1.
Liquid waste that can potentially
deprive receiving waters of
oxygen (for each kilogram
discharged per day)—
(a) biochemical oxygen demand (in
the absence of chemical
oxygen demand limit)
(b) chemical oxygen demand (in
the absence of total organic
carbon limit)
(c) total organic carbon
2.
Biostimulants (for each kilogram
discharged per day)—
(a) phosphorus
(b) total nitrogen
3.
Liquid waste that physically
alters the characteristics of
naturally occurring waters—
(a) total suspended solids (for each
kilogram discharged per day)
(b) surfactants (for each kilogram
discharged per day)
(c) colour alteration (for each
platinum cobalt unit of colour
above the ambient colour of the
waters in each megalitre
discharged per day)
Application form: Works approval or licence (draft released for consultation)
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Department of Environment Regulation
(d) temperature alteration (for each
1°C above the ambient
temperature of the waters in
each megalitre discharged per
day)—
(i)
in the sea south of the
Tropic of Capricorn
(ii) in other waters
4.
Waste that can potentially
accumulate in the environment
or living tissue (for each kilogram
discharged per day)—
(a) aluminium, arsenic, cadmium,
chromium, cobalt, copper, lead,
mercury, molybdenum, nickel,
vanadium and zinc
(b) pesticides
(c) fish tainting wastes
(d) manganese
5.
E coli bacteria as indicator
species (in each megalitre
discharged per day)—
(a) 1 000 to 5 000 organisms per
100 ml
(b) 5 000 to 20 000 organisms per
100 ml
(c) more than 20 000 organisms
per 100 ml
6.
Other waste (per kilogram
discharged per day)—
(a) oil and grease
(b) total dissolved solids
(c) fluoride
(d) iron
(e) total residual chlorine
(f) other
Subtotal
Application form: Works approval or licence (draft released for consultation)
$
16
Department of Environment Regulation
Information and data used to calculate proposed fees
The detailed calculations of fee components, including all Information and data used for the
calculations are provided in the specified annexures to this application.
Proposed fee for works approval
Annexure number
Details for cost of works
Proposed fee for licence
Annexure number
Part 1: Premises
Part 2: Waste types
Part 3: Discharges to air, onto land, into waters
Application form: Works approval or licence (draft released for consultation)
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Department of Environment Regulation
Attachment 10: Request for exemption from publication
Application form: Works approval or licence (draft released for consultation)
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