NOTIFICATION FORM Notification of New (Commissioning) Hazardous Substance Location or Transit Depot The HSNO Act 1996 and the Hazardous Substances (Classes 1 to 5 Controls) Regulations 2001 (Regulations 30, 77, 83, 94, 101, 116 and 124) require the person in charge of commissioning a hazardous substance location or transit depot to notify an Enforcement Officer before commissioning. Note: “commissioning” relates only to the hazardous substances located at the site. Notification time frames Hazardous Substance Location (excluding LPG) or Transit Depot At least 30 working days Hazardous Substance Location (where LPG is to be located) At least 5 working days Site and contact details Company Name (if applicable) Name of Person in Charge Company Street Address Email Address Daytime Phone Number Test Certifier (if one is contracted at this time) Test Certifier’s Contact Phone Indicate whether the site is a Does the HS Location relate to a residential property? Hazardous Substance Location Transit Depot Yes No Summary of hazardous substances Substance Class 1 Maximum Quantity Substance Class 2 Maximum Quantity Substance Class 3 Maximum Quantity Substance Class 4 Maximum Quantity Substance Class 5 Maximum Quantity If Class 2, LPG? Yes No Ministry of Business, Innovation and Employment (MBIE) contact details This completed form should be sent to: The Registrar, Health and Safety Group Response Team, MBIE, PO Box 105146, Auckland or faxed to 09 984 4115 healthsafety.notification@dol.govt.nz Date: _________________ www.epa.govt.nz