REFERENCE DOCUMENTS - RAL25/0004 (As Published)

                                                                                                                                   Notice
                                                                                                              Notifiable Activity
                                                             6. Details of land owner
                  If you are not the landowner,
                  provide the details of the owner of    FULL NAME                                                         TITLE
                  the property (if known).


                                                         POSTAL ADDRESS                                                    POSTCODE



                                                         PHONE                                    FAX



                                                         EMAIL




                  If a joint notification is being           7. Declaration
                  provided by more than one person
                  a signed declaration by each          I declare that:
                  person must be attached.
                                                           •    The information I have provided within this form is true and correct to
                                                                the best of my knowledge.
                                                           •    I understand that all information within or attached to this written notice
                                                                may be disclosed publicly in accordance with the Right to Information
                                                                Act 2009 and the Evidence Act 1977.
                                                           •    I understand that it is an offence under section 480 of the
                                                                Environmental Protection Act 1994 to give the administering authority a
                                                                document containing information that I know is false, misleading or
                                                                incomplete in a material particular.

                                                         NAME

                                                         Larry Sengstock

                                                         SIGNATURE


                                                         DATE

                                                         30/05/2023



                  Please submit this notice using one of the following methods:

                  Email: [email protected]
                  The email subject line should state ‘Written notice of a notifiable activity’.
                  The file size limit for submission via e-mail is 14MB. Any submission via email which exceeds 14 MB will
                  need to be broken down into separate emails, with each email clearly Part X of X (e.g. Part 1 of 2), included
                  in the subject line of the email.

                  Post to:
                  Permit and Licence Management




                 Page 4 of 5 • ESR/2015/1845 • Version 5.00 • Effective: 03 FEB 2020               Department of Environment and Science
Document Set ID: 23717062
Version: 0, Version Date: 01/01/1900