Environmental Protection AuthoritGOVERNMENT OF

WESTERN AUSTRALIA

Referral of a Proposal by a Decision-making authorityto the Environmental Protection Authorityunder Section 38(5) of the Environmental Protection Act 1986

PURPOSE OF THIS FORMSection 38(5) of the Environmental Protection Act 1986 (the EP Act) provides that a decision-making authority that has notice of a proposal that appears to it to be a significant proposal ora proposal of a prescribed class is to refer the proposal the Environmental Protection Authority(EPA) for a decision on whether or not it requires assessment under the EP Act. This formsets out the information requirements for the referral of a proposal by a decision-makingauthority.

Before completing this form, decision-making authorities are encouraged to familiarisethemselves with the EPA's General Guide on Referral of Proposals [see Environmental ImpactAssessment/Referral of Proposals and Schemes].

A referral under section 38(5) by a decision-making authority must be made on this form. Thisform will be treated as a referral provided all required information is included to the extent thatit is pertinent to the proposal being referred. Referral documents are to be submitted in twoformats - hard copy and electronic copy. The electronic copy of the referral will be providedfor public comment for a period of 7 days, prior to the EPA making its decision on whether ornot to assess the proposal.

CHECKLISTBefore you submit this form : have you

Yes NoCompleted all applicable questionsIncluded Attachment 1 - location mapsIncluded Attachment 2 - Supporti information (if applicable)Enclosed the CD of all referral içiformation, including spatial data andcontextual mapping.

Following a review of the information presented in this form, please consider the followingquestion. (A response is Optional)

DO YOU CONSIDER THE PROPOSAL REQUIRES FORMAL ENVIRONMENTALIMPACT ASSESSMENT?

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IF YES. WHAT LEVEL OF ASSESSMENT?ASSESSMENT ON PROPONENT INFORMATIONPUBLIC ENVIRONMENTAL REVIEW; J

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REFERROR'S DECLARATION

(full name) submit this referral to theEnvironmental Protection Autority for consiimpacts.

deration of the environmental significance of its

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1. DMA, PROPOSAL, PROPONENT AND LOCATION INFORMATION1.1 REFERRING DMA

Name

Postal Address WA

4tDMA contact for the proposal

• Name• Phone• Email

1.2 PROPONENT

Name of person/entity proposing to implementthe proposalJoint Venture parties(if applicable)

hPostal Address

Key proponent contact for the proposal• Name• Address• Phone• Email

1.3 PROPOSAL

TitleDescription

1.4 LOCATION

Name of the Shire in which the proposal islocatedFor urban areas -• street address• lot number• suburb• nearest road intersectionFor remote localities -• nearest town• distance and direction from that town to

the proposal siteElectronic spatial data - GIS or CAD on CD,geo-referenced and conforming to thefollowing parameters:• GIS: polygons representing all activities

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and namedCAD: simple closed polygons representingall activities and nameddatum: GDA94projection: Geographic (latitude/longitude)or Map Grid of Australia (MGA)format: Arcview shapefile, Arcinfocoverages, Microstation or AutoCAD

2. APPROVALS/CONTROL MECHANISMS

What approval(s) is (are) required from youas a Decision Making Authority?

Is an amendment to a planning schemeproposed or required to enableimplementation of the proposal?

If yes, please provide details.

Have you sought comments from a StateGovernment Agency or Local Authorityregarding this proposal?

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Yes / CNo.

Not

If yes, name all agencies and LocalAuthorities contacted.

What conditions can you place on the rproposal to manage environmental impacts?

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3. ENVIRONMENTAL CONSIDERATIONS

Jn what ways do you consider the proposalmay have a significant effect on the

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environment and warrant referral to theEPA?

4. SUPPORTING INFORMATION

Please attach copies of relevant information you have received or can provide on theproposal and list documents below.

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