APPLICATION FOR TEMPORARY APPROVAL
UNDER SECTION 30A This form applies to discharge to the environment or to manage wastes:

during a temporary emergency; or

for the temporary relief of public nuisance or community hardship.

Please refer to Publication 1590 when completing this application form.

1.	Applicant

1.1 Company details ENVIRONMENT PROTECTION AUTHORITY VICTORIA

Company name
ACN
Registered address
Postal address
Premises address*
Municipality
Are you an exisiting EPA licence holder? (Y/N)	Licence #

*Also attach a site/premises plan, which clearly indicates any discharge points (if applicable)

1.2 Contact details ENVIRONMENT PROTECTION AUTHORITY VICTORIA

Name
Position
Phone
Email

2.	Description

Provide a simple outline of the event, including the reason it occurred or will occur:
[insert text here]

2.1 Duration
When will or did the event start? (dd/mm/yy)
When is it expected to end? (dd/mm/yy)

2.2 Activities to be undertaken
List options to fix the problem:
[insert text here]
What is the preferred option and why?
[insert text here]

3.	WASTE DISCHARGES

Please boxes relevant to expected discharges/emissions and complete the tables

Tip: If you require additional rows to complete a table, place your cursor in the bottom, right-hand cell of the table and press the TAB button to insert a row.

3.1 Waste discharge expected
List of wastes	Expected amounts	Treatment type	Storage

3.2 Air emissions expected
Air emission source	Indicator (including odour)	Rate or scale of emission	Class 3 indicator?*

*Class 3 indicators are extremely hazardous substances that are carcinogenic, mutagenic, teratogenic, highly toxic or highly persistent (refer the State Environment Protection Policy (Air Quality Management) 2001).
Provide reasons for any air emissions, and the expected duration:
[insert text here]

3.3 Water discharges expected
Discharge location	Rate of discharge (litres/day)	Water quality and treatment level

Provide reasons for any discharge to water, name of receiving water, flow rate, dilution ratio and any downstream impacts. Specify if it is only for discharge to land:
[insert text here]

3.4 Landfill discharges
Rate of discharge or deposit to land	Types of waste and level of treatment

Provide the reasons for any discharge to land or groundwater:
[insert text here]

3.5 Noise emissions
Noise operating hours	Noise sources	How is impact to be minimised?

Describe any noise likely to be audible, and the reasons:
[insert text here]

4.	STAKEHOLDER ENGAGEMENT

Have you identified stakeholders that may be potentially affected by the proposed activity?

Provide details:
[insert text here]

How do you propose to engage with the above stakeholders?
[insert text here]

5.	EXPECTED ENVIRONMENTAL IMPACT

Impact to:	Description of impacts
Air
Land
Surface water
Groundwater

6.	PROPOSED MONITORING

Proccess	Indicator measured	Monitoring type	Monitoring frequency

7.	PROPOSED REPORTING

Frequency	Target date

8.	PREVENTATIVE ACTION

Action taken to prevent the situation from happening again:

Activity	Frequency

9.	APPLICANT STATEMENT

I declare that to the best of my knowledge the information in this form is true and correct: (Signed by company employee who is responsible for managing the site/situation)
Name:	dd
dd
Position:	dd
dd	dd
Signature:	dd
dd
Date: