SUPPLEMENTAL POLLUTION APPLICATION - LANDFILLS
This supplemental application is part of an overall application for coverage. Where answers to
specific questions have already been provided in the main Facilities Application Form there is no
need to repeat the information again in this Supplemental Application Form. Please ensure that all
questions are answered in full and please use additional paper to answer the questions where
necessary.
1.
APPLICANT NAME:
Address (to be completed if different from Facilities Application Form):
2.
Contact:
Title:
Telephone:
Fax:
e-mail Address:
Web Site:
SITE SIZE (ha):
Area of site landfilled (ha):
Is the landfilled area restricted to within the boundaries of the Applicants site?
Yes
No
Please attach a red line plan of the site and surrounds defining the extent of any current,
former and proposed landfilling.
3.
STATUS
Is the landfill open or closed?
Open
Closed
Provide dates of operation:
4.
LICENCING
Is the site currently licenced or has it ever been licenced in the past, for the storage,
handling, treatment or disposal of waste?
Yes
No
If Yes, provide a copy of any licences.
If the landfill is closed, have all closure requirements/restoration works been discharged?
Yes
No
Supplemental Pollution Application - Landfills
Page 1
of 3
Please provide a copy of any closure requirements/restoration works which have
been, or are required to be completed.
5.
(a)
WASTE
Describe the waste types accepted by the landfill, where not specified on the licence.
(b)
Describe any waste types previously licenced or unlicenced, which are likely to have been
accepted by the landfill (include any recorded or anecdotal information).
(c)
If specific waste types were restricted to specific areas of the landfill, please annotate the
site plan with details.
6.
CONSTRUCTION
(a)
Is the landfill (or any part of the landfill) a ‘dilute and disperse’ type of landfill?
Yes
(b)
No
Is the landfill engineered? (e.g. liners, barrier walls, hydrogeological containment, leachate
& gas collection systems).
Yes
No
If Yes, provide details of the engineering, annotating the attached plan to show the location
and extent of any engineered collection, monitoring or containment systems.
(c)
Provide details of the life expectancy of the engineered containment system and details of
any warranties provided by the design and construction companies.
7.
MONITORING AND ENVIRONMENTAL REPORTS
Is the site or surrounds subject to any environmental monitoring (e.g. groundwater, landfill
gas, leachate, odours, sound, etc).
Yes
No
If Yes, provide copies of monitoring data. Annotate monitoring locations on the attached
plan.
8.
OPERATION AND MANAGEMENT
Supplemental Pollution Application - Landfills
Page 2
of 3
(a)
Is the site actively managed, either as part of its licence, aftercare obligations or
otherwise?
Yes
No
If Yes, provide details of contractor and scope of work undertaken.
(b)
Have there been any incidents or complaints from third parties or regulators in relation to
the landfill site (e.g. noise, dust, odour, visual impairment or any other)?
Yes
No
If Yes, provide details.
(c)
Have there been any non-compliances with respect to environmental authorizations,
permits or licences relating to the operations currently or historically undertaken at the site?
Yes
No
If Yes, provide details.
AFTER INVESTIGATION THE APPLICANT REPRESENTS THAT THE FOREGOING STATEMENTS
AND FACTS (TOGETHER WITH ANY CONTAINED ON ADDITIONAL PAGES) ARE TRUE AND THAT
NO MATERIAL FACTS HAVE BEEN SUPPRESSED OR MISSTATED.
COMPLETION OF THIS FORM DOES NOT BIND COVERAGE. APPLICANT'S ACCEPTANCE OF THE
COMPANY'S QUOTATION IS REQUIRED PRIOR TO BINDING COVERAGE AND POLICY ISSUANCE.
IT IS AGREED THAT THIS FORM, AND ANY ADDITIONAL INFORMATION SUPPLIED WITH IT OR IS
IN SUPPORT OF IT (IN TOTAL THE APPLICATION) SHALL BE THE BASIS OF THE CONTRACT
SHOULD A POLICY BE ISSUED. IT IS FURTHER AGREED THAT THE APPLICATION SHALL BE
ATTACHED TO THE POLICY.
Signed on Behalf of:
Applicants Signature:
Applicants Name:
Title:
Date:
Supplemental Pollution Application - Landfills
Page 3
of 3