Underground Petroleum Storage System Leak Notification Form

Notification of a pollution incident to the relevant authority under Part 5.7 of the Protection 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.

This form should be completed where at least one of the following scenarios apply to the UPSS site (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 occured.

SECTION A - UPSS SITE DETAILS

Site name (or name of business)*

Site address*

State*

Postcode*

Suburb*

ABN/ACN (if applicable)

Property details: Lot no:

DP No:

Nature of activity at the site*

Environment Protection Licence number (if applicable)

Dangerous Goods Licence/Notification number (if applicable)

SECTION B - DETAILS OF THE INCIDENT

Date incident occured or leak identified*

Duration of incident (or date leak stopped)*

Nature of incident*

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 (eg. adjoining land uses, other possible source(s) of pollution)

Location of the incident (maps and/or diagrams attached)

SECTION C - PERSON RESPONSIBLE FOR THE UPSS SITE

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

Name

Postal address

Suburb*

State

Postcode*

Phone number

SECTION D - DETAILS OF PERSON WHO SUBMITTED NOTIFICATION

Name*

Position

Address

Suburb*

State*

Postcode*

Phone number

Email*

Date*

To the best of my knowledge, the information provided is true and correct*

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Mandatory field(s) marked with *