Environmental Protection Authority to Form for a request to change implementation conditions the Environmental Protection Act 1986 Change FORM conditions Part A: Proponent information and proposal description Proponent information Name of the proponent/s (including Trading Name if relevant) Australian Company Number(s) OR Australian Business Number(s) Proponent Who is referring this request to change Authorised representative (an authorisation from the implementation conditions? proponent should be provided). Name (print) Signature Organisation Position Email Address Street No. Street Name Suburb State Postcode Date Does the referrer request that the EPA treat any part of the proposal Yes No information in the referral as confidential? Provide confidential information in a separate attachment. Referral declaration for proponent and Authorised representative: I, (full name) ………………………………………………………………, of………………………………………………………………………. declare that I am authorised to refer this request on behalf of the proponent, and further declare that the information contained in this form is true and not misleading. If the referrer is responsible for the proposal but is not the nominated proponent, then an form must be Note: submitted with this Form. Provide contact details for purposes of the assessment, if different from the above. Include: name, physical address, email. Pre-referral discussions Identify outcomes of any pre-referral discussions with EPA Services
Environmental Protection Authority FORM Change to conditions Form for a request to change implementation conditions the Environmental Protection Act 1986 Part A: Proponent information and proposal description Proponent information Name of the proponent/s (including Trading Name if relevant) Australian Company Number(s) OR Australian Business Number(s) Who is referring this request to change implementation conditions? Proponent Authorised representative (an authorisation from the proponent should be provided). Name (print) Signature Position Organisation Email Address Street No. Street Name Suburb State Postcode Date Does the referrer request that the EPA treat any part of the proposal information in the referral as confidential? Provide confidential information in a separate attachment. Yes No Referral declaration for proponent and Authorised representative: I, ………………………………………………………………, (full name) of………………………………………………………………………. declare that I am authorised to refer this request on behalf of the proponent, and further declare that the information contained in this form is true and not misleading. Note: If the referrer is responsible for the proposal but is not the nominated proponent, then an form must be submitted with this Form. Provide contact details for purposes of the assessment, if different from the above. Include: name, physical address, email. Pre-referral discussions Identify outcomes of any pre-referral discussions with EPA Services
Instructions%20and%20template%20-%20Request%20to%20change%20implementation%20conditions%20....docx