Water Act
Pursuant to Section 93
For guidance on completing this form please refer to the Guidelines on Waste Discharge Licensing under the
Water Act available on the Northern Territory Environment Protection Authority (NT EPA) website at http://www.ntepa.nt.gov.au/waste-pollution/guidelines .
This is an approved form in accordance with section 3 of the Water Regulations . Information on this form is being collected for the purposes of assessing your application to amend a waste discharge licence under the
Water Act . Failure to provide the information requested on this form may result in your application not being considered. Information is collected and managed in accordance with the NT EPA Privacy Statement and the Information Act . The privacy statement can be found at: http://www.ntepa.nt.gov.au/privacy .
Licence Holder (the Licence Holder must be a legal entity).
Legal Entity Name:
Trading Name
ABN
Registered Business Address
Street Number
Suburb
ACN
Street Name
State Postcode
Registered Business Address
Postal Address (for all correspondence in relation to this licence application)
PO Box Suburb
State Post Code
Contact Details
All official correspondence will be directed to this person.
Contact Person
B/Hours Phone
Mobile
Position Title
A/Hours Phone
Fax
Email
Licence number: Expiry date of licence:
Legal entity name of licensee:

Please provide contact details for someone who can respond to an incident relating to the licensed activity 24 hours a day.
Name
Position description
Telephone
Number
Please provide the details of the proposed change including a discussion on the potential impacts of the change supported, where applicable, by monitoring data. Applications cannot be processed unless all that appropriate documentation accompanies the application form.
Current condition number and description and or Appendix
Proposed condition description and or Appendix
Reason for the proposed change including supporting data and an assessment of environmental risk.
ENVIRONMENT PROTECTION AUTHORITY

Complete the checklist of elements required in a WDL amendment application indicating what elements are likely to be impacted by the proposed amendments. For further information on each element refer to the
Guidelines for Waste Discharge Licences. Where an element is likely to be impact please address the requirements in the column labelled Comments.
Element No impact Impact
1. Discharge point(s)
Comments
2. Mixing zone
3. Factors to be considered under Section 90 of the
Water Act
Please provide monitoring data with an interpretation and an environmental risk assessment to support any proposed changes to a mixing zone.
4. Environmental Assessment
Please provide an update as to how the requirements of an environmental assessment report have been addressed in relation to the
WDL.
5. Mine Management Plan (or equivalent for petroleum sites)
Please provide a copy of the most current approved mine management plan (part A).
6. WDL justification
7. Continuous improvement plan
8. Discharge specifications
9. Monitoring plan
10. Conceptual site model
11. Environmental aspects and impacts register
12. Emergency response plan
13. Consultation and
Communication plan
Please provide a copy of the most current WDL justification.
Please provide an update on the continuous improvement plan.
Please provide monitoring data with an interpretation and an environmental risk assessment to support the proposed amendments
Please provide monitoring data with an interpretation and an environmental risk assessment to support the proposed amendment(s).
Please provide an update of the conceptual site model.
Please provide a copy of the most current register.
Please provide a copy of the most current emergency response plan.
Please provide a copy of the most current emergency response plan.
ENVIRONMENT PROTECTION AUTHORITY

This declaration must only be signed by a person with the legal authority to sign it (i.e. a person authorised by the Legal Entity specified in this application).
I hereby declare that the information provided in this application and accompanying documents is to the best of my knowledge, true and correct.
Signature
Name (printed)
Position
Date
Seal (if signing under seal):
Section Item
Monitoring data, interpretation and environmental risk assessment.
Environmental Assessment
Complete and Attached
Mine Management Plan (part A)
WDL Justification
Conceptual Site Model
Environmental Aspects and Impacts Register
Emergency Response Plan
Consultation and Communication Plan
ENVIRONMENT PROTECTION AUTHORITY