Development Application part 2 OF 2 All of CD, Information in notes - MCU12/0216

Form

Application for amendment or discharge of financial assurance for an

Please read carefully through the
cerlification opposite before signing.

Where there is more than one
applicant, this cerlification is to be
signed by the person authorised to
sign on behalf of ail applicants (i.e. the
principal applicant).

Where the applicant or principat
applicant is a company, this form Is to
be signed by a person authorised in
writing to sign far that company (i.e.
appointed signatory).

You may apply for exemption from
disclosing information contained In
this application (prursuant to s. 564 of
the EP Act) by completing the form
Application for Disclosure Exemption
(EM873).

Privacy statement

The Department of Environment and
Heritage Protection (EHP) is
committed to pratecting the privacy,
accuracy and security of your
personal information in accordance
with the Information Privacy Act 2008.
EHP is collecting your personal
information in accordance with s. 260
of the Environmental Protection Act
1994 in order to process the
appfication fo transfer an amend or
discharge FA for an environmental
authority (mining activites). The
information will only be accessed by
authorised employees within the
department. Some of this information
may be given to DNRM as part of the
application process. Your information
will not be given to any other person
or agency unless you have given us
permission or we are authorised or
required by law. All information
supplied on this form may be
disclosed publicly in accordance with
the Right to Information Act 2009 and
Evidence Act 1977. For queries about
privacy matters email:
[email protected] or
telephone: (07) 3896 3705.

environmental authority (mining activities)

16, Certification
\We, being the applicants identified at Question 1, hereby apply to:

J amend the amount of financial assurance held for the environmental
authority identified at question Question 3

(1 discharge the full amount of financial assurance held for the
environmental authority identified at question Question 3 \

We request that the administering authority:

(2 _srelease the financial assurance as detailed in question Question 14

(J accept the financial assurance lodged with this application, as detailed
in question Question 15, on behalf of all holders of the environmental
authority identified at question Question 3 *

 

 

1, Greg White
Printed name of person signing this form

 

 

* am authorised to sign on behalf of all applicants, and commit all

applicants in all matters relevant to this application;

certify that the applicants are/were (cross out where relevant) holders of

the environmental authority identified at Question 3;

¢ solemnly and sincerely declare that the information provided is true and

correct to the best of my knowledge and | make this solemn declaration
conscientiously believing the same to be true and by virtue of the
provisions of the Oaths Act 1867;

e understand that all information supplied on or with this application form

may be made available upon request, subject to the Right to Information
Act 2009 and/or by EHP administrative access arrangements;

e am aware that under s. 480 of the Environmental Protection Act 1994, itis

an offence to give the administering authority a document that contains
Information that 1 know is false, misleading or incomplete in any material
particular. The maximum penaity for such action Is 1665 penalty units for
an individual, or 8325 penalty units where the applicant is a corporation
(s. 181B(3) of the Penalties and Sentences Act 1992 (PS Act). Refer to
the PS Act for value of a penalty unit.

 

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Department of Environment and Heritage Protection