2. EA application form

                                                                                                      Application form
            Development application Form 1 - Application details—attachment for an
                                         application for an environmental authority

14. Applicant declaration
I declare that the information I have provided is true and correct. I understand that it is an offence under the
Environmental Protection Act 1994 to give information that I know is false, misleading or incomplete.

I will comply with all conditions on my environmental authority as well as any relevant provisions in the
Environmental Protection Act 1994.

I understand that I am responsible for managing the environmental impacts of these activities, and that approval
of this application is not an endorsement by the administering authority of the effectiveness of the management
practices proposed or implemented.
 Applicant’s full name*                                             Applicant’s position*
 Oscar Rogers                                                       Coastal Flooding and Foreshore Officer

 Applicant’s signature*                                             Date*
                                                                    22-12-2022




Submit attachment, together with any additional information, with all relevant
Development application Forms to the assessment manager for the development
application.




Page 10 of 12 • ESR/2015/1791 • Version 8.00 • Last reviewed: 12 AUG 2021             Department of Environment and Science