EOFM-006-01
Waste Management and Pollution Control Act (2009)
APPLICATION FOR AN ENVIRONMENT PROTECTION APPROVAL
Pursuant to Section 31(2)
For guidance on completing this form, you should refer to the Guide to Environment Protection Approvals
and Licences under the Waste Management and Pollution Control Act. The guide is available from the
Northern Territory Environment Protection Authority (telephone 8924 4218) or on the website at
www.ntepa.nt.gov.au
Information on this form is being collected in accordance with section 31 of the Waste Management &
Pollution Control Act for the purpose of assessing your application for a licence under the 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 Northern Territory Environment Protection
Authority Privacy Statement and the Information Act. The privacy statement can be found at:
www.ntepa.nt.gov.au
1. APPLICANT DETAILS
Proposed Approval Holder
The approval holder must be an individual(s), body corporate or public authority not a partnership, trust or
joint-venture name.
Full name of Applicant who will
Legally hold Approval
ABN
ACN
Contact Information
All official correspondence will be directed to this person.
Name
Position
B/Hours Phone
A/Hours Phone
Mobile
Fax
Email
Business Address
Street Number
Suburb
State
Postcode
Postal Address
PO Box
Suburb
State
Post Code
Duration
The duration of this approval will in any event be subject to any statutory approval to commence activities
provided by another Authority.
Please state the preferred number of years that you wish your approval to be in force.
Application for an Environment Protection Approval
Last Reviewed: Sept 11
Page 1 of 16
NORTHERN TERRITORY ENVIRONMENT PROTECTION AUTHORITY
2. EMERGENCY CONTACT
Please provide contact details for someone who can respond to an incident relating to the approved activity
24 hours a day.
Name
Position
B/Hours Phone
A/Hours Phone
Mobile
Fax
Email
3. ACTIVITY DETAILS
Please tick all activities that you are proposing to undertake and ensure that you attach all the appropriate
supporting documentation as per section 9 of this form. Please refer to the Guide to Environment Protection
Approvals and Licences Under the Waste Management and Pollution Control Act for clarification of activities.
Activity
Regulation
Reference
Characteristics

A1
Solid Waste
Disposal
Section 30,
Schedule 2,
Part 1(1)
Constructing, installing or carrying out works in relations to
premises for disposal of waste by burial, other than:
o Domestic waste generated by domestic residence and
disposed of on the land on which the premises is situated;
o Domestic waste from temporary construction camps;
o Waste generated by pastoral activities that is disposed of
on the land on which the pastoral activities are carried out;
o Waste rock, rubble and other inert materials used for the
purpose of reclaiming land; and
o Waste of a prescribed class.
A2
Listed Waste
Disposal
Section 30,
Schedule 2,
Part 1(2)
Constructing, installing or carrying out works in relation to
premises, other than a sewerage treatment plant, associated
with disposal of listed waste (i.e. asbestos, tyres) on a
commercial or fee for service basis.
A3
Listed Waste
Storing,
Recycling and/or
Treating
Section 30,
Schedule 2,
Part 1(2)
Constructing, installing or carrying out works in relation to
premises, other than a sewerage treatment plant, associated
with storing, recycling and/or treating listed waste on a
commercial or fee for service basis.
A4
LNG or Methanol
Plant
Section 30,
Schedule 2,
Part 1(3)
Constructing, installing or carrying out works in relation to
premises for processing hydrocarbons to produce, store and/or
dispatch liquefied natural gas (LNG) or methanol, where:
o the premises are designed to produce more than 500,000
tonnes annually of LNG and/or methanol; and
o no lease, licence of permit under the Petroleum Act or the
Petroleum (Submerged Land) Act relates to the land in
which the premises is situated.
A5
Blacktip Gas
Project
Section 30,
Schedule 2,
Part 1(4)
Constructing an onshore gas plant as part of the Blacktip Gas
Project within the meaning of the Trans-Territory Pipeline and
Blacktip Gas Projects (Special Provisions) Act 2005.
If you ticked activity A1 go to Section 4.
If you ticked any of the activities from A2 to A3 complete Attachment 1 and go to Section 5.
If you ticked any of the activities from A4 to A5 go to Section 5.
Application for an Environment Protection Approval
Last Reviewed: Sept 11
Page 2 of 16
NORTHERN TERRITORY ENVIRONMENT PROTECTION AUTHORITY
4. WASTE STREAMS
Please specify the population that your facility intends to service.
Please complete the following table.
Quantities per Annum
Tick
Waste Category
Brief Description and Sources
m3
tonne
Municipal Solid
Waste
Green Waste
Commercial &
Industrial Waste
Construction &
Demolition Waste
Listed Waste
If you ticked Listed Waste you must ensure that you have ticked Activities A2 and/or A3 as well as Activity A1
in section 3 and provide the relevant supporting documentation as specified in section 9 of this from.
5. LOCATION OF PREMISE TO BE LICENCED
Please attach a map showing the location, design and layout of the whole of the premises, and provide the
following details of the location of the premises.
Premise commonly known as (if applicable)
Street Number
Lot Number
Street Name
Suburb
State
Post Code
Title Reference
Folio identifier or volume-folio (if Torrens Land
System)
Registered deed number (if Old Land System)
Longitude
Easting
Latitude
Point 1:
Point 1:
Point 2:
Point 2:
Point 3:
Point 3:
Point 4:
Point 4:
Northing
Site Reference
AMG Zone
Reference System (GDA94, WGS84, AGD)
Local Government Area
If there are any conditions or restrictions placed on the usage of the land by either the owner or other
authorities please provide details of these as an attachment.
Application for an Environment Protection Approval
Last Reviewed: Jan-13
Page 3 of 16
NORTHERN TERRITORY ENVIRONMENT PROTECTION AUTHORITY
6. CONSENT OF OWNER/OCCUPIER
If the applicant does not own the site, please provide details of the owner.
Full Name of Land or Premise Owner
Street Number
Street Name
Suburb
State
B/Hours Phone
A/Hours Phone
Mobile
Fax
Postcode
You must provide evidence that you have consent of the owner of the site to conduct this activity.
7. VEHICLE WASH FACILITIES
Will you have vehicle wash facilities?
YES
NO
If you answered ‘YES’ please attach plans and drawings for the facility including the type of oil/water
separator, sediment and gross pollutant traps and any maintenance and performance monitoring schedules.
If you answered ‘NO’ please attach details of where you will be washing vehicles.
Application for an Environment Protection Approval
Last Reviewed: Jan-13
Page 4 of 16
NORTHERN TERRITORY ENVIRONMENT PROTECTION AUTHORITY
8. DISCHARGE POINTS
Will any of the activities you listed in Section 3 discharge pollutants to air, water or land?
YES
NO
If you answered ‘NO’ to this question, go to Section 9
If you answered ‘YES’ to this question, please attach a map of the premises showing the location of all
discharge points for pollutants to air, water or land and identify each discharge point with a number.
If the discharge is to land for the purposes of irrigation, mark the area of land to which the discharge will be
applied.
Discharges to Air
Please provide details of all discharge points to air.
Discharge Point 1
Discharge Point 2
Discharge point 3
Discharge Point 4
Label of discharge point
on map
Longitude (decimal
degrees)
Latitude (decimal
degrees)
Easting (6 digits)
Northing (7 digits)
AMG Zone
Reference System (e.g.
GDA94, WGS84, AGD)
Description of location of
discharge point
Please ensure that all discharges to air have been included. Attach extra pages if more space is required.
Application for an Environment Protection Approval
Last Reviewed: Jan-13
Page 5 of 16
NORTHERN TERRITORY ENVIRONMENT PROTECTION AUTHORITY
Discharges to Water
Please provide details of all discharge points to waters.
Discharge Point 1
Discharge Point 2
Discharge point 3
Discharge Point 4
Label of discharge point
on map
Longitude (decimal
degrees)
Latitude (decimal
degrees)
Easting (6 digits)
Northing (7 digits)
AMG Zone
Reference System (e.g.
GDA94, WGS84, AGD)
Description of location of
discharge point
Maximum volume to b e
discharged during any 24
hour period (kilolitres)
Catchment Name
Name of receiving waters
(e.g. Daly River, Rapid
Creek)
Type of receiving waters
(e.g. open coastal,
enclosed, estuarine)
Please ensure that all discharges to water have been included. Attach extra pages if more space is required.
Application for an Environment Protection Approval
Last Reviewed: Jan-13
Page 6 of 16
NORTHERN TERRITORY ENVIRONMENT PROTECTION AUTHORITY
Discharges to Land
Please provide details of all discharges to areas being used for the application of liquid waste, wastewater,
effluent or biosolids on, to or into land points to waters.
Discharge Point 1
Discharge Point 2
Discharge point 3
Discharge Point 4
Label of discharge point
on map
Longitude (decimal
degrees)
Latitude (decimal
degrees)
Easting (6 digits)
Northing (7 digits)
AMG Zone
Reference System (e.g.
GDA94, WGS84, AGD)
Description of location of
discharge point
Maximum volume to be
discharged during any 24
hour period (kilolitres)
Catchment Name
Name of nearest waters
(e.g. Daly River, Rapid
Creek)
Please ensure that all discharges to land have been included. Attach extra pages if more space is required.
Application for an Environment Protection Approval
Last Reviewed: Jan-13
Page 7 of 16
NORTHERN TERRITORY ENVIRONMENT PROTECTION AUTHORITY
9. SUPPORTING DOCUMENTATION
Please ensure that you have attached all the supporting documentation stipulated below for your
activity(ies). Refer to the Guide to Environment Protection Approvals and Licences Under the Waste
Management and Pollution Control Act for guidance.
Applications will not be processed unless all the appropriate supporting documentation
accompanies the application form.
Activity Document Title
Tick
Development Consent Permit
Environmental Impact Statement (where applicable)
Location Map in relation to surrounding area and land uses.
Map of site design and layout.
Vehicle Wash Bay Specifications.
A1
Discharge Specifications (if applicable).
Environmental Aspects and Impacts Register.
Procedures for the Management of all Environmental Aspects related to your activity.
Emergency Response Plan that addresses the Environmental Aspects of construction (e.g.
spill, fire etc).
Monitoring Plan (Surface Water, Ground Water, Dust, Sediment).
Compliance Plan.
Development Consent Permit
Environmental Impact Statement (where applicable)
Location Map in relation to surrounding area and land uses.
Map of site design and layout.
Vehicle Wash Bay Specifications.
Discharge Specifications (if applicable).
A2
Environmental Aspects and Impacts Register.
Procedures for the Management of all Environmental Aspects related to your activity.
Procedures for how you will dispose of Listed Waste.
Emergency Response Plan that addresses the Environmental Aspects of construction (e.g.
spill, fire etc).
Monitoring Plan (Surface Water, Ground Water, Dust and Sediment).
Compliance Plan.
Attachment 1 – as per Section 3 above
Application for an Environment Protection Approval
Last Reviewed: Jan-13
Page 8 of 16
NORTHERN TERRITORY ENVIRONMENT PROTECTION AUTHORITY
Development Consent Permit
Environmental Impact Statement (where applicable)
Location Map in relation to surrounding area and land uses.
Map of site design and layout.
Vehicle Wash Bay Specifications.
Discharge Specifications (if applicable).
Environmental Aspects and Impacts Register.
A3
Procedures for the Management of all Environmental Aspects related to your activity.
Procedures for the storage, recycling and/or treating of Listed Waste.
Facility details for where Listed Waste will be stored (e.g. bunding, ventilation, spill kits etc)
Emergency Response Plan that addresses the Environmental Aspects of operations (e.g.
spill, fire etc).
Monitoring Plan (Surface Water, Ground Water, Dust, Sediment and Emissions)
Compliance Plan.
Attachment 1 – as per Section 3 above
Development Consent Permit
Environmental Impact Statement (where applicable)
Location Map in relation to surrounding area and land uses.
Map of site design and layout.
Vehicle Wash Bay Specifications.
A4
Discharge Specifications (if applicable)
Environmental Aspects and Impacts Register.
Procedures for the Management of all Environmental Aspects related to your activity.
Emergency Response Plan that addresses the Environmental Aspects of operations (e.g.
spill, fire etc).
Monitoring Plan (Surface Water, Ground Water, Dust, Sediment, Biological and Emissions).
Compliance Plan.
Application for an Environment Protection Approval
Last Reviewed: Jan-13
Page 9 of 16
NORTHERN TERRITORY ENVIRONMENT PROTECTION AUTHORITY
Development Consent Permit
Environmental Impact Statement (where applicable)
Location Map in relation to surrounding area and land uses.
Map of site design and layout.
Vehicle Wash bay Specifications.
A5
Discharge Specifications (if applicable).
Environmental Aspects and Impacts Register.
Procedures for the Management of all Environmental Aspects related to your activity.
Emergency Response Plan that addresses the Environmental Aspects of operations (e.g.
spill, fire etc).
Monitoring Plan (Surface Water, Ground Water, Dust, Sediment, Biological and Emissions).
Compliance Plan.
Application for an Environment Protection Approval
Last Reviewed: Jan-13
Page 10 of 16
NORTHERN TERRITORY ENVIRONMENT PROTECTION AUTHORITY
10. APPROVAL FEE
The Waste Management and Pollution Control (Administration) Regulations detail the fees for Environment
Protection Approvals issued under the Waste Management and Pollution Control Act.
These can be found in the Fees Payable list available on our website www.ntepa.nt.gov.au
Applicants who intend to conduct more than one scheduled activity and/or at multiple premises under the Act
are required to pay the sum of all fees due for each activity and premises to which they require an Approval.
Fees are to accompany the Approval application form. Fees can be paid by Credit Card by completing the
details below or by Cheque. Cheques are to be made out to the ‘Receiver of Territory Monies’.
Processing will not commence until the correct fee has been received.
CREDIT CARD PAYMENT DETAILS
Card Type
NAME ON CREDIT CARD:
CREDIT CARD NUMBER
Card Expiry Date:
/
Fee Amount to be deducted: $
Cardholder Signature: _______________________________________
Application for an Environment Protection Approval
Last Reviewed: Jan-13
Date:
/
/
Page 11 of 16
NORTHERN TERRITORY ENVIRONMENT PROTECTION AUTHORITY
11. DECLARATION
This declaration must only be signed by a person(s) with the legal authority to sign it. The ways in which the
application may be signed, and the people who may sign the application, are set out in the categories below.
If the proposed licence
holder is:
An individual
Tick The application must be signed and certified by one of the following:
The individual.
The common seal being affixed in accordance with the Corporations Act, or
Two directors, or
A company
A director and a company secretary, or
If a proprietary company that has a sole director who is also the sole
company secretary – by that director.
The Chief Executive Officer (CEO) of the public authority, or
A public authority
By a person delegated to sign on the public authority’s behalf in accordance
with its legislation (Please note: a copy of the relevant instrument of
delegation must be attached to this application).
I/We hereby declare that the information provided in this application and accompanying documents
is to the best of my/our knowledge, true and correct.
Signature
Signature
Name (printed)
Name (printed)
Position
Position
Date
/
/
Date
/
/
Seal (if signing under
seal):
Once completed and signed, this form, the application fee and appropriate attachments should be
sent to:
Environmental Operations Unit
Northern Territory Environment Protection Authority
GPO Box 3675
DARWIN NT 0801
Application for an Environment Protection Approval
Last Reviewed: Jan-13
Page 12 of 16
NORTHERN TERRITORY ENVIRONMENT PROTECTION AUTHORITY
OFFICE USE ONLY
DATE APPLICATION RECEIVED
INVOICE NUMBER
FEE RECEIVED
/
/20
RECEIPT NUMBER
APPLICATION APPROVED / NOT APPROVED
NEW APPROVAL OR LICENCE NUMBER
Application for an Environment Protection Approval
Last Reviewed: Jan-13
/
/20
EPA
Page 13 of 16
NORTHERN TERRITORY ENVIRONMENT PROTECTION AUTHORITY
ATTACHMENT 1: LISTED WASTE DETAILS
Disposal
Recycling
Treatment
Storage
Transport
Listed Waste
Collection
Please tick the appropriate boxes for the types of listed waste and activities you propose to conduct. You
must attach documentation that demonstrates how you handle/manage each type of listed waste and copies
of dangerous goods approvals where relevant.
Acidic solutions or acids in solid form
Animal effluent and residues
Antimony, antimony compounds
Arsenic, arsenic compounds
Asbestos
Barium compounds other than barium sulphate
Basic solutions or bases in solid form
Beryllium, beryllium compounds
Boron compounds
Cadmium, cadmium compounds
Ceramic-based fibres with physio-chemical characteristics similar to
those of asbestos
Chlorates
Chromium compounds that are hexavalent or trivalent
Clinical and related wastes
Cobalt compounds
Containers that are contaminated with residues of a listed waste
Copper compounds
Cyanides (inorganic)
Cyanides (organic)
Encapsulated, chemically fixed, solidified or polymerised wastes
Ethers
Filter cake
Fire debris and fire washwaters
Fly ash
Grease trap waste
Halogenated organic solvents
Application for an Environment Protection Approval
Last Reviewed: Jan-13
Page 14 of 16
Disposal
Recycling
Treatment
Storage
Transport
Listed Waste
Collection
NORTHERN TERRITORY ENVIRONMENT PROTECTION AUTHORITY
Highly odorous organic chemicals (including mercaptans and acrylates)
Inorganic fluorine compounds excluding calcium fluoride
Inorganic sulfides
Isocyanate compounds
Lead, lead compounds
Mercury, mercury compounds
Metal carbonyls
Nickel compounds
Non-toxic salts
Organic phosphorus compounds
Organic solvents excluding halogenated solvents
Organohalogen compounds that are not otherwise specified in this
Schedule
Percholates
Phenols, phenol compounds including chlorophenols
Phosphorus compounds other than mineral phosphates
Polychlorinated dibenzo-furan (any cogener)
Polychlorinated dibenzoo-p-dioxin (any cogener)
Residue from industrial waste treatment or disposal operations
Selenium, selenium compounds
Sewerage sludge and residues including nightsoil and septic tank
sludge
Soils contaminated with a listed waste
Surface active agents (surfactants) that contain principally organic
constituents and that may contain metals and inorganic materials
Tannery wastes (including leather dust, ash sludges and flours)
Tellurium, tellurium compounds
Thalium, thallium compounds
Triethylamine catalysts for setting foundry sands
Tyres
Vanadium compounds
Application for an Environment Protection Approval
Last Reviewed: Jan-13
Page 15 of 16
Disposal
Recycling
Treatment
Storage
Transport
Listed Waste
Collection
NORTHERN TERRITORY ENVIRONMENT PROTECTION AUTHORITY
Waste chemical substances arising from research and development or
teaching activities, including those substances which are not identified
and/or are new and the effects of which on human health and/or the
environment are not known
Wastes containing peroxides other than hydrogen peroxide
Waste containing cyanides from heat treatment and tempering
operations
Waste from the manufacture, formulation and use of wood preserving
chemicals
Waste from the production, formulation and use of biocides and
phytopharmaceuticals
Waste from the production, formulation and use of inks, dyes, pigments,
paints, lacquers and varnish
Waste from the production, formulation and use of organic solvents
Waste from the production, formulation and use of photographic
chemicals and processing materials
Waste from the production, formulation and use of resins, latex,
plasticsers, glues and adhesives
Waste from the production and preparation of pharmaceutical products
Waste mineral oils unfit for their original intended use
Waste mixtures, or waste emulsions, of oil and water or hydrocarbon
and water
Waste pharmaceuticals, waste drugs and waste medicines
Waste resulting from surface treatment of metals and plastics
Waste tarry residues arising from refining, distillation and any pryolytic
treatment
Waste substances and articles containing or contaminated with
polychlorinated biphenyls (PCBs), polychlorinated nalthalenes (PCNs),
polychlorinated terphenyls (PCTs) and/or polybrominated biphenyls
(PBBS)
Waste of an explosive nature not subject to the Dangerous Goods Act
Wool scouring waste
Zinc compounds
Application for an Environment Protection Approval
Last Reviewed: Jan-13
Page 16 of 16