APPLICATION FORM
SPECIAL EMERGENCY
Application Form: Use a Hazardous
Substance in a Special Emergency
Import for release, release from containment, or use any hazardous substance in a special
emergency under section 49D of the Hazardous Substances and New Organisms Act 1996
Send by post to: Environmental Protection Authority, Private Bag 63002, Wellington 6140
OR email to: HSApplications@epa.govt.nz
Name of substance(s):
Applicant:
Date:
OFFICE USE ONLY
Application code
Date received
EPA contact
Application version no.
www.epa.govt.nz
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Import for Release, Release from Containment, or Use any Hazardous Substance in a Special Emergency
Completing this application form
1. This form has been approved under section 47 of the Hazardous Substances and New Organisms
(HSNO) Act 1996. The form covers approval to import for release, release from containment, or use, any
hazardous substance in the event of a special emergency or impending special emergency. A special
emergency means an adverse event that is declared by a responsible Minister 1 to be a special
emergency under section 49B of the HSNO Act.
2. It is recommended that you contact an advisor at the EPA as soon as possible. They can help you scope
and prepare your application, and speed up the application process.
3. This application form may be used to seek approvals for more than one hazardous substance if the
substances are used for the same purpose in a special emergency, and are of a similar nature.
4. Any extra material that does not fit in the application form must be clearly labelled, cross-referenced, and
included as appendices to the application form.
5. Confidential information must be collated in a separate appendix. You need to justify why you consider
the material to be confidential, and ensure it is clearly labelled as such.
6. This application form (with the exception of any information contained in a confidential appendix) may be
made publicly available.
7. The application must include the information required by the EPA that, depending on the special
emergency, the applicant can provide in the time available.
8. The application form may be completed manually or electronically; however, the form must be signed
manually. Print the application form to do this. Scan and submit the application form by email or submit by
post.
9. If you are completing the form electronically, use the mouse to move between fields or press the  or 
arrows on your keyboard. You may copy and paste from other documents.
10. The EPA will complete a rapid assessment of the application as soon as practicable after receiving the
application.
11. For more information or further help, please contact our staff.
Environmental Protection Authority, Private Bag 63002, Wellington, New Zealand
Telephone: 64 4 916 2426
Facsimile: 64 4 914 0433
Email: HSApplications@epa.govt.nz
http://www.epa.govt.nz
1
‘Responsible Minister’ is defined in section 49A of the HSNO Act.
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Import for Release, Release from Containment, or Use any Hazardous Substance in a Special Emergency
1. Applicant details
1.1 Applicant
Company name:
Contact name:
Job title:
Physical address:
Postal address:
(provide only if not the same as the physical)
Phone:
(office and/or mobile)
Fax:
Email:
Signature
This application must be signed by the applicant or the applicant’s contact indicated in 1.1.
I request the EPA to waive any legislative information requirements (ie, concerning the information that
shall be supplied in my application) that my application does not meet. [Tick if applicable]
I have completed this application to the best of my ability and, as far as I am aware, the information I have
provided in this application form is correct.
Signature
Name:
April 2013 EPA0183
Date
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Import for Release, Release from Containment, or Use any Hazardous Substance in a Special Emergency
2. Information about the application
2.1 Purpose statement
Using the tick-boxes below, please indicate the purpose that applies to the hazardous substance use in the
special emergency. Please also provide a short summary statement of the purpose of this application for the
EPA public register (maximum of 255 characters, including spaces and punctuation).
Import for release
Yes
No
Manufacture in containment
Yes
No
Release from containment
Yes
No
Use in a manner that would contravene the HSNO Act or any Regulations
Yes
No
Purpose statement:
2.2 Unique name for public register
If the substance has an existing HSNO approval, enter the name and approval code from the Controls for
Approved Hazardous Substances database: http://www.epa.govt.nz/search-databases/Pages/controlssearch.aspx (EPA website).
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Import for Release, Release from Containment, or Use any Hazardous Substance in a Special Emergency
2.3 Executive summary

Complete the following table.

Include any commercially sensitive information in the confidential appendix to this form.
Name of substance
Name of active ingredient
Physical description
Hazardous properties
Emergency use
Description of emergency
Intended use of substance
Necessity to use the substance
Potential adverse effects
Risk management measures
2.4 Details of the special emergency declaration
Please attach a copy of the notice in the New Zealand Gazette (if it has been issued).
Describe the special emergency.
Include the situation, location, user/s and expected timeframe. Be as specific as possible.
Which responsible Minister has declared/is likely to declare the special emergency?
If the special emergency has not yet been declared, when is it likely to be declared?
When will notice of the declaration of the special emergency be published in the New Zealand Gazette?
When will the special emergency expire (if known)?
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Import for Release, Release from Containment, or Use any Hazardous Substance in a Special Emergency
2.5 Detail why the substance is necessary to deal with the special emergency.
Please include details on:

the availability and viability of alternative measures to deal with the emergency

consequences of the substance not being approved for use

data to demonstrate the efficacy of the substance for the proposed use.
2.6 Detail how the substance will be used in the special emergency.
If relevant, please include details on:

Application rates

Application frequency

Intervals between applications.
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Import for Release, Release from Containment, or Use any Hazardous Substance in a Special Emergency
3. Information on the hazardous substance

Include any commercially sensitive information in the confidential section of this form.

Provide details on the active ingredient(s) as well as the mixture in this section.
3.1 Identity of the active ingredient(s):
Active ingredient (common name):
Chemical name (IUPAC):
Chemical name (CA):
Molecular formula:
Structural formula:
Manufacturer’s development codes:
CIPAC No:
CAS No:
Function:
Herbicide
Fungicide
Insecticide
Other (specify):
FAO specification (including year of publication):
Yes
Minimum purity of the active ingredient as manufactured (g/kg):
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Plant growth regulator
No
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Import for Release, Release from Containment, or Use any Hazardous Substance in a Special Emergency
3.2 Composition details of the mixture:
Full composition details must be supplied.
Please confirm the following:
Full details are provided below.
I have arranged for the owner of the substance details to provide details to the EPA using a copy of this
page.
Owner of the mixture details
Physical address
Postal address
Provide only if not the same as the
physical
Postal address
Phone
Switchboard number
Fax
Email
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Import for Release, Release from Containment, or Use any Hazardous Substance in a Special Emergency
CAS number
Component name2
Function of
component3
Concentration4
(g/L or g/kg)
Active ingredient(s)
Other ingredients
Total weight/weight (solids) or weight/volume (liquids)
Specific gravity (liquids only)
Formulation type
Does the product contain any viable new organisms, including genetically
modified organisms?
Including purity details where relevant – eg, 95% purity, sufficient to give 100 g/L. Trade names cannot be used on their own.
If trade name products are used as an ingredient, provide full formulations of all trade name products used, or arrange to have
complete formulations sent directly to the EPA by the supplier (see Section 3.2).
2
3
The purpose of the ingredient in the formulation (eg, solvent, binder, preservative etc). Do not use ‘inert’.
4
The nominal concentration of the ingredient, including overages and allowing for impurities.
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Import for Release, Release from Containment, or Use any Hazardous Substance in a Special Emergency
4. HSNO hazard classifications of the substance
4.1 Identify the HSNO hazard classification of the mixture
Fill in the table where and as appropriate.
Hazard class/subclass
Hazard classification
Class 1
Explosiveness
Class 2, 3 & 4
Flammability
Class 5
Oxidisers/Organic Peroxides
Subclass 8.1
Metallic corrosiveness
Subclass 6.1
Acute toxicity (oral)
Subclass 6.1
Acute toxicity (dermal)
Subclass 6.1
Acute toxicity (inhalation)
Subclass 6.3/8.2
Skin irritancy/corrosion
Subclass 6.4/8.3
Eye irritancy/corrosion
Subclass 6.5A
Respiratory sensitisation
Subclass 6.5B
Contact sensitisation
Subclass 6.6
Mutagenicity
Subclass 6.7
Carcinogenicity
Subclass 6.8
Reproductive/ developmental
toxicity
Subclass 6.9
Target organ systemic toxicity
Subclass 9.1
Aquatic ecotoxicity
Subclass 9.2
Soil ecotoxicity
Subclass 9.3
Terrestrial vertebrate ecotoxicity
Subclass 9.4
Terrestrial invertebrate ecotoxicity
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Remarks
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Import for Release, Release from Containment, or Use any Hazardous Substance in a Special Emergency
4.2 Overseas countries that have declined the substance (if any)
Please also include any countries that have revoked or withdrawn approval.
4.3 Expert reports
Please attach any expert reports (including those of overseas regulatory agencies) pertaining to the
substance.
4.4 Label
Please attach the substance label or draft label.
4.5 Manufacturing processes
Please describe any relevant manufacturing practices and standards, and state whether these are satisfied.
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Import for Release, Release from Containment, or Use any Hazardous Substance in a Special Emergency
5. Identification and management of risks
You must include a proposed management plan (section 6), detailing measures to control the adverse effects
of the substance in a special emergency.
The proposed methods to manage the adverse effects should be summarised below.
5.1 Please provide information on the identification and assessment of positive and adverse effects of the
mixture on the environment.
5.2 Are there any potential adverse or beneficial effects when considering the relationship of Māori and
their culture and traditions with their ancestral lands, water, sites, waahi tapu, valued flora and fauna
and other taonga?
Also consider the effects of this application on the principles of the Treaty of Waitangi.
5.3 Are there any potential social, economic, cultural, ethical or spiritual effects?
5.4 Are there effects related to New Zealand’s international obligations?
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Import for Release, Release from Containment, or Use any Hazardous Substance in a Special Emergency
6. Management plan
Please provide any other information that may be relevant to the application.
Please attach a proposed plan for dealing with the hazardous substance in the special emergency. This plan
should detail how the special emergency is to be dealt with.
The plan must include:

the measures that must be taken to avoid, remedy, or mitigate any actual or potential adverse effects
from the use of the hazardous substance, and

the requirements for the disposal of the hazardous substance and any waste products.
Please include an explanation of how the proposed plan adequately controls the adverse effects of the hazardous
substance.
Where possible, please refer to the relevant Hazardous Substances Regulations – eg:

Identification (documentation and labelling)

Packaging

Emergency management,

Personnel qualification (eg, approved handler or controlled substance licence requirements).
If the substance has an existing HSNO approval (with the exception of the emergency use), please indicate
where controls in the existing approval apply throughout the lifecycle, and where deviations are intended in the
emergency situation.
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Import for Release, Release from Containment, or Use any Hazardous Substance in a Special Emergency
7. Other information
Please provide any other information that may be relevant to the application.
7.1 List of appendices
7.2 List of references
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Import for Release, Release from Containment, or Use any Hazardous Substance in a Special Emergency
Appendix 1 – Confidential material
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