Underground Petroleum Storage Systems - Registration Form

Site Information

*Business Name:

Business Address

Unit Number:
*Street/Lot Number:
*Street Name:
*Suburb:
*Postcode:
*Telephone Number:

Location Data

The following location data is available on the LIST using the instructions in the box below.

Property ID:
Title reference/s (volume/folio):
Easting of Underground Storage System (GDA94):
Northing of Underground Storage System (GDA94):
Note: If there is more than 100m between Underground Storage Systems then please include Eastings and Northings for each Underground Storage System:

Persons Responsible for complying with Regulations

Note: Please ensure that for each address you need to fill in that you use the following format:

e.g.

---

System Operator #1		System Operator #2
*Name:		Name:
*Postal Address:		Postal Address:
*Street Address:		Street Address:
Phone Number:		Phone Number:
Email:		Email:
Infrastructure Owner #1		Infrastructure Owner #2
*Name:		Name:
*Postal Address:		Postal Address:
*Street Address:		Street Address:
Phone Number:		Phone Number:
Email:		Email:
Landowner #1		Landowner #2
*Name:		Name:
*Postal Address:		Postal Address:
*Street Address:		Street Address:
Phone Number:		Phone Number:
Email:		Email:

Additional system operators, infrastructure owners and/or landowners:

Underground Petroleum Storage System (UPSS) Information

*Type of activity conducted on site:

-- Select an item -- Service Station Farm Light Industry Heavy Industry Commercial Domestic

Equipment

*Total number of underground tanks on the site in use on 31 March 2010:
*Number of those tanks that are double-walled:
*Number of underground tanks with double-walled lines/piping:
*Total capacity of all underground tanks in use on the site (litres):

Loss Monitoring

*If loss monitoring is undertaken please select which methods are used regularly.

None Inventory reconciliation Statistical inventory reconciliation Equipment integrity tests Manual tank gauging Other (please state below) Note: Inventory reconciliation = comparison of fuel in, fuel out and tank dips.

Other:

Groundwater Monitoring Wells

*Are groundwater monitoring wells installed on the site?	YesNo
Number of wells:
Are the wells used to check for leaks from the UPSS?	YesNo

Privacy Statement

Personal information is being collected from you for the purpose of enhancing the protection of the environment and will be used for the administration and implementation of the Environmental Management and Pollution Control (Underground Petroleum Storage Systems) Regulations 2010. The information may be used for other purposes permitted by the Regulations.

You are required to provide this information under regulation 37 of the Environmental Management and Pollution Control (Underground Petroleum Storage System) Regulations 2010. Failure to provide this information may result in penalties applying.

Your personal information will be used for the primary purpose for which it is collected, and may be disclosed to other agencies and land use planning authorities, law enforcement agencies, courts and other organisations authorised to collect it.

Your basic personal information may be disclosed to other public sector bodies where necessary, for the efficient storage and use of the information.

Personal information will be managed in accordance with the Personal Information Protection Act 2004 and may be accessed by the individual to whom it relates on request. You may be charged a fee for this service.

Submitting Form

Please ensure that all compulsory fields (*) are completed before submitting this information:

I declare that the information I have given is true and correct to the best of my knowledge.

*The above statement is true:	I Agree
*Name:
Date:	29/01/2012

Note: A printable view of the information you are about to submit is available after submission of this form.