Petrol Service Station Business Registration Form

PETROL SERVICE STATION

BUSINESS REGISTRATION FORM

This form is to be completed by all petrol service stations operating within the City of Canada Bay.

For further information, please contact Council on 9911 6555.

Purpose of submitting *

Initial RegistrationUpdate DetailsCeased to OperateOther

If other, please specify

Business Details

Trading Name *

Business Address *

Business Postcode *

Company Name *

ABN/ACN *

Address for Service of Documents *

Postcode *

Person Responsible Details

Person Responsible for a storage systems in use refers to the person who has management and control of the storage system/s.

Name *

Position/Title *

Phone (w) *

Phone (m) *

Email Address *

After Hours Contact details

After Hours Name *

After Hours Position/Title *

After Hours phone (m) *

After Hours Email *

Site Specific details

Annual Petrol Throughput of the Petrol Service Station for the Last 2 Years (Or designed throughput for new stations)

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Year *

Throughput (Litres) *

Is the service station new, or was it upgraded/modified since November 2009? *

YesNo

A modified petrol service station means an existing petrol service station on which works requiring development consent are carried out that involve opening the forecourt, opening the petrol product lines, modification of the storage tanks, tank vents, petrol dispensers or tanker connection points.

Number of tanks onsite *

Please specify details of underground storage tanks in the table below. N.B: If tanks contain multiple compartments,record each compartment as a separate tank.

Year Tank Commissioned *

Tank Volume (L) *

Contents/Fuel Type *

Tank Material *

Have any tanks been decommissioned on site? *

YesNo

Please provide a copy of the relevant validation report. *

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Loss Monitoring System

Loss monitoring system in place? *

YesNoN/A

Type of Loss monitoring system in place *

Monthly Loss Monitoring report produced? *

YesNo N/A

Groundwater Monitoring

Groundwater Monitoring Wells installed as secondary Leak Detection System? *

YesNo

Please specify alternative leak detection system in place onsite *

Groundwater sampled from the monitoring wells and tested at least every 6 months? *

YesNoN/A

Fuel System Operation Plan (FSOP)

FSOP onsite, up to date and readily available *

YesNo

Please upload a copy of the FSOP *

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Vapour Recovery Stage 1

VR 1 system installed and operating *

YesNo N/A

VR 1 Automatic pressure monitoring system installed *

YesNo N/A

VR 1 Date of commissioning

Vapour Recovery Stage 2

VR 2 system installed and operating *

YesNo N/A

VR 2 Automatic pressure monitoring system installed *

YesNo N/A

VR 2 Date of commissioning

Important Information

Any change to the information provided in this form must be notified to Council within one month of the change beingmade.

An authorised officer of Council will inspect the site to assess the premises for compliance with legislative requirements. An inspection fee will be charged in accordance with Council’s Fees and Charges.

For further information please contact Council’s Environmental Health Team on 9911 6555 during business hours orvisit www.canadabay.nsw.gov.au

Declaration

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

Occupier/Proprietor Name *

Occupier/Proprietor Signature *

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Date *

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