Annual Audit Compliance Report Form Environmental Protection Act 1986, Part V Once completed, please submit this form either via email to , or to the below postal address: Department of Water and Environmental Regulation Locked Bag 33 Cloisters Square PERTH WA 6850 Section A Licence Details – Licence file number: Licence number: Licence holder: Trading as: ACN: Registered address: Reporting period: to Section B Statement of Compliance with Licence Conditions – Did you comply with all of your licence conditions during the reporting period? (please tick the appropriate box) Yes please complete: – section C; section D if required; and sign the declaration in Section F. No please complete: – section C; section D if required; section E; and sign the declaration at Section F. Section C Statement of Actual Production – Provide the actual production quantity for this reporting period. Supporting documentation is to be attached. Prescribed Premises Category Actual Production Quantity Section D Statement of Actual Part 2 Waste Discharge Quantity – Provide the actual Part 2 waste discharge quantity for this reporting period. Supporting documentation is to be attached. Prescribed Premises Category Actual Part 2 Waste Discharge Quantity Section E Details of Non-Compliance with Licence Condition –
Annual Audit Compliance Report Form Environmental Protection Act 1986, Part V Once completed, please submit this form either via email to , or to the below postal address: Department of Water and Environmental Regulation Locked Bag 33 Cloisters Square PERTH WA 6850 Section A – Licence Details Licence number: Licence file number: Licence holder: Trading as: ACN: Registered address: Reporting period: to Section B – Statement of Compliance with Licence Conditions Did you comply with all of your licence conditions during the reporting period? (please tick the appropriate box) Yes – please complete: section C; section D if required; and sign the declaration in Section F. No – please complete: section C; section D if required; section E; and sign the declaration at Section F. Section C – Statement of Actual Production Provide the actual production quantity for this reporting period. Supporting documentation is to be attached. Prescribed Premises Category Actual Production Quantity Section D – Statement of Actual Part 2 Waste Discharge Quantity Provide the actual Part 2 waste discharge quantity for this reporting period. Supporting documentation is to be attached. Prescribed Premises Category Actual Part 2 Waste Discharge Quantity Section E – Details of Non-Compliance with Licence Condition