Leak Notification Form for Underground Petroleum Storage Systems

LEAK NOTIFICATION FORM

FOR UNDERGROUND PETROLEUM STORAGE SYSTEMS (UPSS)

Notification of a pollution incident to the relevant authority under Part 5.7 of theProtection of the Environment Operations Act 1997 (POEO Act)

The person responsible for the UPSS must, immediately after becoming aware of a pollution incident, notify the relevant authority. Where the notification was verbal, a written notification using this form must be submitted within seven days. The person responsible is the person who has management and control of the UPSS.

For further information, please contact Council on 9911 6555.

This form should be completed where at least one of the following scenarios apply to the UPSS site. Please tick where appropriate. *

A leak from a UPSS, verified in accordance with loss detection or incident management procedures, that is causing or threatens material harm to human health or the environment.There is evidence on the site of free-phase hydrocarbons in surface water and/ or groundwater.There is evidence that offsite migration of hydrocarbons could occur, is occurring, or has occurred.

Section A: UPSS Site Details

Site name (or name of business) *

ABN/ACN *

Site Street Address *

Site Postcode *

Nature of activity at the site *

Environmental Protection Licence number If applicable.

Dangerous Goods Licence/Notification Number and date of ExpiryIf applicable.

Section B: Details of the incident

Date incident occured/leak identified *

Duration of incident (or date the leak stopped) *

Nature of incident *

For other, please specify

If other, please specify

Estimated quantity or volume of pollutants involved *

Action taken or proposed to be taken to deal with the incident and any resulting pollution or threatened pollution *

Any additional information (e.g. adjoining land uses, other possible source(s) of pollution)

Section C: Person responsible for the UPSS site

If the 'person' responsible is a corporation, an individual who is authorised to act on the organisations behalf must be nominated.

Name *

Phone Number *

Contact person (if person responsible is not a natural person)

Postal Address *

Postal Postcode *

Section D: Details of person who submitted notification

I declare that to the best of my knowledge, the information provided in this application is accurate and correct.

Declarant Name *

Position *

Address *

Postcode *

Email *

Signature *

Draw signature|Type signatureClear

Date *