This form is to be used by former holders of a registration certificate to apply to convert a previously surrendered registration certificate to a suspended environmental authority under section 698B of the Environmental Protection Act 1994 (EP Act).
This application form is relevant for prescribed environmentally relevant activities (ERAs) only and cannot be used for resource activities. It can only be used until the 31 March 2015, which is when this provision expires.
If you would like to have a pre-lodgement meeting:

For prescribed ERAs 2, 3 and 4 —contact the Department of Agriculture, Fisheries and Forestry by email at livestockregulator@daff.qld.gov.au
.

For any other ERA —please fill out and lodge the form Application for a Pre-Design/Pre-Lodgement
Meeting (EM1125 1 ), prior to lodging this application form.
GUIDE
If you require assistance in answering any part of this form, or have any questions about your application please contact the relevant department.
Contact details are at the end of this form.
The registration certificate details may be found on the surrendered registration certificate.
If more space is required for any responses, please attach additional information as a separate page.
If there is an agent acting on behalf of the former holder of the registration certificate, provide details in this section. An agent could be a consultant or a contact for the environmental authority holder.
As statutory documents need to be sent to all applicants, this section can also be used when there are multiple holders of the former registration certificate, to nominate an address for statutory
FORMER REGISTRATION CERTIFCATE NUMBER
FORMER REGISTERED OPERATOR NAME
Agent details/address for service
INDIVIDUAL OR BUSINESS NAME (INCLUDE TRADING NAME IF RELEVANT)
RESIDENTIAL ADDRESS OR REGISTERED BUSINESS ADDRESS (NOT A POST OFFICE BOX
ADDRESS)
POSTAL ADDRESS (IF DIFFERENT FROM ABOVE)
CONTACT PERSON
1 This is the publication number. The publication number can be used as a search term to find the latest version of a publication at www.qld.gov.au
.
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• 130331 • EM948 • Version 1

Application to convert a surrendered registration certificate to a suspended environmental authority documentation to be sent
‘care of’ to.
The address supplied here will also be used as a service address for sending statutory documents. If blank, statutory documents will be sent to the principal holder of the former registration certificate.
PHONE
EMAIL
FACSIMILE
If this conversation application is approved, the anniversary day of the environmental authority will be the same as the anniversary day that applied to the surrendered registration certificate.
ANNIVERSAY DAY (DAY/MONTH)
ERA
NUMBER
NAME OF ERA OR ACTIVITY THRESHOLD
The suspension period must end at least 1 year from the next anniversary day and can be no longer than 3 years from the next anniversary day i.e. the suspension must be for a minimum of 1 year but no longer than 3 years.
You must not commence any activities approved under the environmental authority until the suspension period ends and, if any financial assurance is required, the financial assurance is given. Annual fees will also be payable once the suspension period ends.
PROPOSED SUSPENSION END DATE
I understand that should this application be approved, the conversion effects will be as follows:
From the day of the conversion:

Any former holders of the surrendered registration certificate will become the holders of a suspended environmental authority.

Any former holders of the surrendered registration certificate will
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Application to convert a surrendered registration certificate to a suspended environmental authority

 become registered suitable operators and their names, addresses and
ABN/ACN/AN(s) will be published on a public register of suitable operators.
If the surrendered registration certificate related to a development permit, the development conditions will become the conditions of the suspended environmental authority.
If the surrendered registration certificate related to a code of environmental compliance, then the standard environmental conditions of the code of environmental compliance will become the standard conditions of the suspended environmental authority.
The first step towards payment is to calculate the fees payable.
Information on these fees can be located in the information sheets Fees for Permits for
Environmentally Relevant
Activities (ERAs) (EM33) available at www.qld.gov.au
.
To pay by credit card you will need to provide contact details so you can be contacted for your credit card payment to be made over the phone.
The application fee is: $
You may pay your fee via cheque, money order or credit card.
Select the payment method below:
Payment by cheque or money order made payable to the
Department of Environment and Heritage Protection
(attached).
Payment by cheque or money order made payable to the
Department of Agriculture, Fisheries and Forestry (attached).
Please contact me (the applicant) for credit card payment:
Phone number:
Where there was more than 1 holder of the former registration certificate, this declaration is to be signed by all holders, unless there is an agreement between all holders that 1 can sign on behalf of the other.
Note: If only 1 holder is signing this application form, they are committing all holders to the content of the application and the declaration.
Where the former registration certificate holder is a company, this form must be signed by an authorised person for that company.
Privacy statement
The Departments of
Environment and
Heritage Protection
Note: If you have not told the truth in this application you may be prosecuted.
Where an agreement is in place between all holders of the former registration certificate, that 1 holder can sign on behalf of the other joint holders, please tick the below checkbox.
I have the authority to sign this form on behalf of all the joint holders of the former registration certificate.
I declare that:

I am the former holder of the surrendered registration certificate or an authorised signatory.

The information provided is true and correct to the best of my knowledge. I understand that it is an offence under section 480 of the Environmental
Protection Act 1994 to give to the administering authority or an authorised person a document containing information that I know is false, misleading or incomplete in a material particular
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Application to convert a surrendered registration certificate to a suspended environmental authority
(EHP) and Agriculture,
Fisheries and Forestry
(DAFF) are collecting the information on this form to process your conversion application.
This collection is authorised under sections
284B, 698B, 698C and
698D of the
Environmental Protection
Act 1994 . If your application is approved your name, address and
ABN/ACN/AN will be disclosed on the Register of Suitable Operators which will be publicly available on the EHP website. This disclosure is authorised by section
318I(1)(b) of the
Environmental Protection
Act 1994 .
Your personal information will only be accessed by authorised employees within these departments and will not be disclosed to any other parties unless authorised or required by law. For queries about privacy matters please email privacy@ehp.qld.gov.au or telephone:
(07) 3330 5436.

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

I understand that I am responsible for managing the environmental impacts of these activities, and that approval of this application is not an endorsement by the administering authority of the effectiveness of management practices implemented.

I understand that the register of suitable operators will be publicly available.
NAME
SIGNATURE
POSITION OF SIGNATORY DATE
JOINT HOLDER’S SIGNATURE (IF APPLICABLE) JOINT HOLDER’S NAME (IF
APPLICABLE)
JOINT HOLDER ’S NAME (IF
APPLICABLE)
JOINT HOLDER ’S SIGNATURE (IF APPLICABLE)
Application form complete and any supporting information attached.
Fees paid or enclosed.
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Application to convert a surrendered registration certificate to a suspended environmental authority
Further information
The latest version of this publication and other publications referenced in this document can be found at www.qld.gov.au
using the relevant publication number
(EM948 for this document) as a search term.
For ERA 2, ERA 3 or ERA 4
Post:
Senior Environmental Scientist
Animal Industries
Department of Agriculture, Fisheries and Forestry
PO Box 102
TOOWOOMBA QLD 4350
For all other ERAs
Post:
Department of Environment and
Heritage Protection
GPO Box 2454
BRISBANE QLD 4001
Enquiries:
Phone: (07) 4688 1374
Fax: (07) 4688 1192
Email: livestockregulator@daff.qld.gov.au
Courier or hand delivery:
Permit and Licence Management
Department of Environment and
Heritage Protection
Level 3, 400 George Street
BRISBANE QLD 4000
Business hours: 8:30am –4:30pm business days
Enquiries:
Permit and Licence Management
Phone: 13 QGOV (13 74 68)
Fax: (07) 3330 5875
Email: palm@ehp.qld.gov.au
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