Form 1A: Supplementary Application Form for the Storage, Use,
and/or Manufacture of Hazardous Substances
Form to be filled out in conjunction with Form 1 Land Use Consent Application
PART A – HAZARDOUS SUBSTANCES
Are there any hazardous substances proposed to be stored or used on site, i.e. flammable liquids, solids, gases? If yes, please list
the nature, including quantities and types of these substances:
Chemical Name
Hazard Classification
Quantity
State whether used/
stored/manufactured
PART B – ASSESSMENT OF EFFECTS ON THE ENVIRONMENT (AEE)
Will the use, storage or manufacture of hazardous substances pose a risk within the site and/or in the surrounding environment
(including natural and physical resources, and people)? Please explain.
Are there any sensitive activities such as schools, rest homes, hospitals, shopping centres, houses etc in the vicinity of your
proposal? Include the distance to those activities.
Are there any sensitive natural resources such as lakes, rivers, wetlands, habitats in the vicinity of your proposal? Include the
distance to these features.
What number of people would be at risk in the event of an accident or emergency involving the substance(s)?
What do you consider the risk to be adjacent to the property in the event of an accident or emergency involving the
substance(s)?
Are there other hazardous facilities or operations in the vicinity? If yes is the potential risk increased as a result of the proposed
new activity?
What is the site drainage system and pattern? (please include a plan)
Are there reticulated services provided to the boundary of this site? Will the hazardous substance have any effect on these
services, and if yes, how will they be avoided, remedied or mitigated?
How are hazardous substances to be transported to and from the site? (a map including entranceway to and from the site should
be supplied)
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Does the transport move through sensitive areas?
What quantities and types of substances are to be transported?
Are emergency procedures in place in the event of an accident or emergency through the transport?
Are alternative methods of use, storage or manufacture available? If yes, why was this method chosen?
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Given the risks and issues identified above are any methods available or proposed to avoid, remedy or mitigate the risks? These
can include (amongst other things):
•
Site configuration;
•
Location of materials;
•
Site management and spill contingency plans;
•
Transport methods and routes;
•
Monitoring; and/or
•
Maintenance schedules.
PART C - ADDITIONAL INFORMATION
The provision of correct and accurate information will enable the effective processing of your application and will ensure that
delays are kept to a minimum.
Please provide the following information with your application:
•
A site plan which shows the location of the storage/use/manufacture of hazardous substances, drainage systems on the
site and/or the pattern of drainage over the site and site entranceways.
•
Affected Party Approvals from the New Zealand Fire Service, New Zealand Police and Community and Public Health are a
standard requirement for hazardous substances resource consent applications. These should be provided with your
application.
CONTACT DETAILS
GREY DISTRICT COUNCIL
105 Tainui Street
PO Box 382, Greymouth
Phone: 03 769 8607 Fax: 03 769 8610 Email: planning@greydc.govt.nz
www.greydc.govt.nz
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