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~ x=,=J, Government of Western Australia ·- . · Department of Environment Regulation

Application form: works approval/licence

Division 3, Part V, Environmental Protection Act 1986 {EP Act) Environmental Protection Regulations 1987 (EP Regulations)

To the Chief Executive Officer

This is an application for [select only one option]

This application Is for the category/categories of prescribed premises

[Refer to DER's Guidance Statement: Licensing and works approval process for further Information on activities which will be subject to works approval/licensing.

INSTRUCTIONS

0 Works approval

0 Works approval Including clearing of native vegetation (Clearing Permit)

D Concurrent works approval and licence or registration

0 Licence

Registration number:[

Works approval number: [ [8J Renewal

Licence number: [L4533/1967/15]

D Amendment Licence or works approval number: [

0 Registration {works approval already obtained) Works approval number:[ ]

D Application for a clearing permit already submitted Clearing permit application number: [ ]

D Single category of prescribed premises (specify category number): [

[8J Multiple categories of prescribed premises (specify category numbers): [12 , 43, 61A, 62, 63]

D All activities on the premises within category of prescribed premises of Schedule 1 to the Environmental Protection Regulations 1987 have been specified above (tick if Yes)

• The application form must be completed with all Information attached. This form Is a statutory requirement under section 54(1 )(a) for works approval applications, section 57(1 )(a) for licence applications, and regulation SB of the Environmental Protection Regulations 1987 for registration.

• If an application form has been submitted which Is Incomplete or materially Incorrect, the CEO will decline to deal with the application under the EP Act and advise the Applicant accordingly.

• The Instructions set out In this guideline to complete the application form are general In nature.

• A reference to 'you' In these instructions Is a reference to the Applicant.

• Works approval only applies for new works approvals. For works approvals for existing premises, please select 'Amendment'.

• Concurrent applications for works approval and licence (or registrations) are encouraged. This means a single application Is submitted.

• Applicants seeking further information relating to requirements under the EP Act are recommended to review the Act through the State Law Publisher (www.slp.wa.gov.au)

• For premises where activities fall within more than one category of prescribed premises, ALL categories must be licensed and identified. This applies for existing licensed premises seeking renewal or amendment, as well as new licensed premises.

Guideline and appl ication form for applications (March 2016 V 3) 1

Department of Environment Regulation

COMPLETION MATRIX The matrix below explains what sections are required to be completed for different types of applications.

Application Form Section New Application/ Renewal Amendment Registration

Part 1 Applicant details - section 1.1 • • • Part 1 section 1.2 onwards • N/A I\

Part 2 Premises • N/A /I

Part 3 Proposed Activities • N/A /I

Part 4 Other Approvals • N/A /\

Part 5 Fit and competent operator • N/A N/A

Part 6 Public health and environmental • N/A (1

risks

Part 7 Siting and location • N/A N/A

Part 8 - not In use

Part 9 Submission of any other relevant • If required . If required. Information

Part 10 Proposed fee calculation • • N/A

Part 11 Submission of application • • • Acknowledgement and signature • • • Attachment 1 A: Proof of Applicant status • N/A N/A

Attachment 18: ASIC Company Extract • N/A N/A

Attachment 2: Map for proposed premises • N/A {\

Attachment 3A: Proposed activities • N/A 1\

Attachment 38: Map for proposed area to • N/A N/A be cleared (only applicable If clearing Is proposed)

Attachment 4: Other approvals • N/A 1\

Attachment 5: Fit and competent operator • N/A N/A

Attachment 6: Public health and • N/A ,, environment risks

Attachment 7: Siting and location • N/A {\

Attachment 9: Other relevant Information If required. N/A If required.

Attachment 10: Proposed fee calculation • N/A N/A

Attachment 11 : Request for exemption If required. N/A If required. f rom publication

Key:

• Must be submitted 1\ To the extent changed/required in relation to the amendment N/A Not required with application, but may be requested subsequently depending onDER records

"If required" are sections for applicants to determine.

Guideline and application form for applications (March 2016 V3) 2


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1.1 Applicant name Cockburn Cement Limited (full legal name)

ACN (if applicable) 008673470

1.2 Directors details (If applicant Is a small proprietary company)

1.3 Registered business address (Registered with ASIC)

1.4 Address for correspondence

1.5 Contact person details Name

Position

Telephone

Email

1.6 Authorised representative Name (If any)

Telephone

Email

1.7 Applicant's representative Name (If any)

Telephone

Email

1.8 Occupier status Registered proprietor on certificate of title 0

[One of the options must be Lease holder (please specify) 0

selected and If you have Public authority that has care, control or management of the land 0 been asked to specify, please provide details] Other (please specify- for example, joint venture operating entity or

contractor. Note contractual arrangements will need to be provided to evidence land owner's consent to occupancy arrangements. If 0 contractual arrangements are not finalised, reason why occupancy consent will be granted will need to be provided.)

Proof of occupier status 1.9 [Instructions set out In Attachment 1A completed 0

Attachment 1A]

ASIC Company Extract 1.10 [Instructions set out in Attachment 1 B completed 0

Attachment 1 B]


. Department of Environment Regulation

INSTRUCTIONS

• Your full legal name must be inserted. Business names are not accepted. If a small proprietary company, the Directors' full names must also be provided.

• A proprietary Is defined by ASIC as small for a financial year if It satisfies at least two of the following paragraphs:

the consolidated revenue for the financial year of the company and any entitles It controls Is less than $25 million

the value of the consolidated gross assets at the end of the financial year of the company and any entitles It controls Is less than $12.5 million, and

the company and any entitles It controls have fewer than 50 employees at the end of the financial year.

• The address for correspondence can be the same as the registered business address.

• Details for a contact person must be provided (where you are an individual, you would be the contact person).

• Details for any authorised representatives must be provided (e.g. consultant) but only If you authorise that person to represent you and that person can be contacted by the Department in relation to your application.

• Details of the occupation of the premises must be provided. One of the options must be selected and if you have been asked to specify, please provide details. For example, If 'Lease holder' has been selected, please specify the type of lease-e.g. pastoral lease, mining lease, general lease.

• You must provide proof of ownership In Attachment 1. Instructions are set out In Attachment 1.

twnam-~11Imm

2.1 Premises legal description (whole or part to be specified)

[Land description: volume and folio number, lot or location number(s), Crown lease or reserve number, pastoral lease number or mining tenement number of ali properties, as shown on title details registered with Landgate)

2.2 Local government authority area

[City, Town or Shire)

2.3 GIS coordinates

[GIS coordinates must be provided where cadastre are not used as the premises boundary)

2.4 An aerial photograph and map of premises

Attachment 2 completed 0 [Instructions set out in Attachment 2]



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3.1 Description/overview

(Instructions set out below Attachment 3A completed D and In Attachment 3A)

3.2 Estimated operating period (based on estimated Infrastructure life)

3.3 Proposed date for commencement of works

3.4 Expected production

3.5 Design capacity

3.6 Throughput (in addition to 3.4 or 3.5)

3.7 Proposed clearing area (hectares and/or number of trees) - only required If application Includes clearing

3.8 Proposed method of clearing (if applicable)

3.9 Period within which clearing Is proposed to be undertaken (e.g. May 2015- June 2015) (if applicable)

3.10 Map of area proposed to be cleared (If applicable)

Attachment 38 completed D [Instructions set out In Attachment 38)

INSTRUCTIONS

• You must provide the scope, size and scale of all prescribed activities of Schedule 1 to the Environmental Protection Regulations 19871ncludlng the maximum design capacity and the expected production capacity.

• You must Identify emission discharge points.

• You must also provide information on any other activity undertaken on the Premises If activity poses a risk to public health or the environment.

• You only need to provide Information on the processes or operations of prescribed activities If they are unique or non-industry standard processes or operations. Instructions are set out in Attachment 3A.

• If you are applying for a clearing permit you must provide the period within which clearing Is proposed to be undertaken (e.g. May 2015 - June 2015) and a description of the method by which It will be undertaken.

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NIA No Yes

4.1 Is the proposal a Major Resource Project (fonnerly known as a State Development 0 D Project)?

Major Resource Projects include mining and petroleum activities or infrastructure projects which support mining and petroleum activities.

4.2 Has the proposal been referred to the Environmental Protection Authority? D 0 D

4.3 Is the proposal subject to any Ministerial conditions under the Environmental D D D Protection Act 1986?

4.4 Has the proposal been referred or assessed under the Environment Protection D 0 D and Biodiversity Conservation Act 1999 (Commonwealth)?

4.5 Has the proposal obtained all relevant planning approvals? D 0 0

4.6 Has the proposal obtained all other necessary statutory approvals? 0 0 0 4.7 Has consultation been undertaken with parties considered to have a direct Interest 0 0 0 In the proposal?



4.8 Other Approvals

[Instructions set out in Attachment4)

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Attachment 4 completed

Note: Under this section, DER will undertake an Internal due diligence of the applicant's fitness and competency based on DER's compliance records.

0

If you wish to provide additional Information for DER to consider In making this assessment, you may provide that Information in Attachment 11 (where It will not be published except where an application has been made, and only In accordance with, the Freedom of Information Act 1992).

No Yes

5.1 Has the applicant held or been part of a small proprietary company that has held a previous licence or works approvals?

0 0 If yes, specify name of company and/or licence or works approval instrument number In Attachment 5.

5.2 If Yes to 5.1 or where the applicant wishes to provide additional information for DER's consideration, Attachment 5 completed.

Note: For an applicant that Is a small proprietary company, each director must complete this section 0 as an Individual, and Include their previous history as directors of other small propriety companies.

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No Yes

6.1 Is there an emission to air from the activities that poses a risk to public health or the 0 0 environment?

(includes emissions from stacks, chimneys, baghouses, blow offs, dust, noise and odour emissions)

6.2 Is there an emission to surface water from the activities that poses a risk to public health 0 0 or the environment?

(includes end of pipe or outfall emissions to river, Jakes, estuary or seas and pollution from containment overflow)

6.3 Is there an emission to land from the activities that pose a risk to public health or the 0 0 environment?

(includes point source emissions to groundwater including direct aquifer reinjection or deep well injection, as well as emissions to land through Irrigation and infiltration and seepage pits.

6.4 Is there a risk of other Incidents arising from the activities that pose a risk to public health 0 0 or the environment?

(Includes risk of a pollution incident or unplanned event related to hazardous materials or dangerous goods stored, used or handled)

6.5 Is there waste accepted, stored or recycled on the premises? 0 0

Waste type must be described with reference to Landfilf Waste Classification and Waste Definitions 1996 (as amended December 2009) or the Environmental Protection (Controlfed Waste) Regulations 2004. Detail must be provided on storage type (e.g. hardstand, containment Infrastructure), capacity and containment features (lining, bunding).

6.6 Public health and environmental risks

Attachment 6 completed 0 [Instructions set out in Attachment 6]

Guideline and application form for applications (March 2016 V3} 6


INSTRUCTIONS

• You must provide detail on source (e.g. kiln stack), contaminants (e.g. particulates) and quantity (mgfm3) of the emission. Instructions are set out In Attachment 6.

• All material sources of emissions where there Is a risk to public health or the environment, and for which there Is a receptor must be Identified. This Includes where you may consider this to be a low risk.

• The risk to public health or the environment and proposed controls are to be specified.

No Yes

7.1 Are there sensitive receptors located within specified separation distances from the premises? D D

In considering sensitive receptors and separation distances refer to DER's Guidance Statement: Separation Distances.

7.2 Are the premises located within or adjacent to any Specified Ecosystems such as wetlands, surface water, groundwater or terrestrial areas?

In considering Specified Ecosystems refer to DER's Guidance Statement: Environmental Siting.

7.3 Siting and Location

[Instructions set out In Attachment 7]


Specified Ecosystems are defined In DER's Guidance Statement: Separation Distances.

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8 :1 Is \h(Jre-! <HI emission thnl requires scrP.r:ming as per the Guicianco Statement: Assessment Ft <JtnCIVOrl. <Jncl undcrpinninf,J c rnission guidelines?

8.2 / \II scrccninn C~ssossmcnls required under Guidmu;e Slillenw nt: Assessment Fmmowork e1nd urHJm pi nnin~ omis::;ion guidHiinos completHd .

No

83 All dci <Jilcd assessrnents wll it:h nray include survcy/lwsnline m0niloring, prcdrclivu •nodc ll inn ond <:~ ny ol11er studies required throuull lh<~ GuiclcJ/1G() Stillr.nmnt: Assussrnont Framawor /1 completed.

8.4 Complin11co with rclov<Jnl onvironmontal si<JnclnrcJ or r.upporlinn infonnnlion for va11atiorr from cnvironmcnl<J I sl<md<lrd.

8 .5 /\sse~~ment Fr.~rnewotk

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All8chmcnl B]

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No

9 Additional Information Attachment 9 completed D submitted

Supplementary documentation submitted D List title of supplementary documenVs In Attachment 9

10.1 All information and data used for the calculation of proposed fees provided.

D

D

Yes

Yes

D

0

Detail of costs of works must include site works (e.g. levelling and drainage), construction works, plant and equipment hire and labour.

Guideline and application form for applications (March 201 6 V3) 7


10.2 Fee details [Instructions set out In Attachment 1 0]

INSTRUCTIONS


Fee calculators are available online to assist In completing this section. • Licence fee calculator: www.der.wa.gov.aulllcenceFeeCalculator.

• Works approval fee calculator. WYffl.der.wa.gov.auM'orksapprovaiFeeCalculator.

. " ( 1~r~

All information considered exempt from public disclosure has been separately placed In Attachment 11 . Grounds for claiming exemption In accordance with Schedule 1 to the Freedom of Information Act 1992 must be specified.

A full electronic copy has been submitted via: jnfQ@Q~r.wa.gov.au

A full hard copy has been sent to: APPLICATION SUBMISSIONS Department of Environment Regulation Locked Bag 33 Cloisters Square PERTH WA 6850

I,

Dinesh Kapadia Operations Manager WA (name) (position)

I confirm I am authorised on behalf of the applicant to submit this application.

[81

0

[81

I confirm that the Information contained in this application Is true and correct and I acknowledge that knowingly providing Information which is false or misleading In a material particular commits an offence under section 112 of the Environmental Protection Act 1986 and may Incur a penalty of up to $50,000. I acknowledge that this application (excluding Attachment 11) is a public document and may be published. I confirm that Information considered exempt from public disclosure has been placed In Attachment 11 with reasons as to why the lnfom1ation should be exempt In accordance with the grounds specified In Schedule 1 to the Freedom of Information Act 1992. I acknowledge that subsequent Information provided In relation to this application will be a public document and may be publish unless written notice has been given to the Department of Environment Regulation by the applicant, at the time the Information is provided, claiming that the Information is considered exempt from public disclosure. I acknowledge that the decision to not publish information will be at the discretion of the Department of Environment Regulation and will be made consistently with the provisions of the Freedom of Information Act 1992.

Date (Signature)



ATTACHMENT CHECKLIST

You must provide copies of certificate of title, lease or other instruments evincing proof of occupier status.

Attachment 1 B: ASIC Company Extract

You must provide a company extract (showing current company information only) from ASIC.

Attachment 2: Map for proposed premises

You must provide an aerial photograph of sufficient scale showing the proposed premises. You must also provide a map of the proposed premises, identifying:

(a) layout of key Infrastructure and buildings, clearly labelled; and (b) lot boundaries,

No Yes

D D

No Yes

D D

with a north arrow, clearly marking the area In which the activities are carried out and of reasonable clarity and visible scale.

Attachment 3A: Proposed activities

You must provide details of proposed activities, Identifying: (a) scope, size and scale, including details as to frequency, production and design capacity; (b) key infrastructure and equipment; (c) unique or non-industry standard processes or operations; and (d) emissions discharge points.

Attachment JB: Map for proposed area to be cleared (only applicable If clearing is proposed)

No Yes

D D

No Yes

D D

You must provide an aerial photograph or map of sufficient scale showing the proposed clearing area and premises boundary or if you have facilities a digital map on CDR OM of the area to clear as an ESRi shape file with the following properties:

•Geometry type: polygon shape

•Coordinate system: GOA 1994 (Geographic latitude/longitude) Datum: GOA 1994 (Geocentric Datum of Australia 1994)

Attachment 4: Other approvals

No

D

Yes

D

You must provide details of other approvals specified in section 4 of this application, including copies of relevant decisions and any consultation undertaken with interested parties.

No Yes

D D



Attachment 5: Fit and competent operator

You must specify name of the small proprietary company/companies that you have been Involved In that have previously held a licence or works approval instrument, or provide the licence or works approval Instrument number.

No Yes

0 0 Attachment 6: Public health and environment risks

You must provide details of public health and environment risk (Including risks you have assessed as low), Identifying: (a) Source of emissions, Specific emissions, Receptors and proximity and Proposed controls. Providing details

of specific emission quantities may not be relevant for some emissions such as odour, noise and dust or emissions arising from Incidents or unplanned events.

(b) Waste type (including waste generated onsite), quantity, storage and location of waste which relate to activities that fall within the category of prescribed premises In Schedule 1 to the Environmental Proteclfon Regulalfons 1987.

Set out below Is a suggested format for specifying waste types.

Waste Type Quantity Storage Location

You must provide a map showing siting and location of the premises to a 5km radius Including Identification of distances to sensitive receptors. Calculation of distance should be made in accordance with the Guidance Statement: Environmental Siting and the Guidance Statement: Separa/fon Distances.

Should the premises be In locations Identified through Guidance Statement: Environmental Siting, further Information Including depth to groundwater, water quality and beneficial uses must be provided.

Applicants seeking to submit further Information may Include information in Attachment 9.

Where supplementary documentation is submitted, please specify name of documents below.

Attachment 10: Proposed fee calculation

In the form provided: see following Attachment.

Attachment 11 : Request for exemption from publication

In the form provided: see following Attachment

Guideline and application form for applications (March 2016 V3)

No Yes

0 0

No Yes

0 0

No Yes

0

No Yes

0 r8l

10


Attachment 10: Proposed fee calculation

Summary of proposed fees

Proposed works approval fee (see Schedule 3 of the Environmental Protection Regulations 1987)

Fee component Proposed fee

Cost of works: $ $

Proposed licence fee (see Schedule 4 of the Environmental Protection Regulations 1987)

Part 1 Component 13,588.82

Part 2 Component 7127.30

Part 3 Component 116,489.48

Total proposed licence fees: $137,205.60

Note: (1) DER has fee calculators available on Its website: - Licence: www.der.wa.gov.au/LicenceFeeCalculator; and -Works approval: www.der.wa.gov.auM'orksApprovaiFeeCalculator.

(2) Different Fee Units apply for different fee components. Fee Units may also have different amounts depending on the period in which the calculation is made.

Detailed breakdown of proposed licence fees

Premises component

Proposed licence fee: Part 1 Premises (see Part 1 of Schedule 4 of the Environmental Protectfon Regulations 1987)

Premises: 12- Screening, etc. Of material (More than 500 000 but not more than 5 000 000 tonnes per year ($10191 .62) 43- Cement or Lime Manufacturing (More than 100 000 tonnes per year) ($13588.62) 61A- Solid waste facility (More than 10 000 but no more than 100 000 tonnes per year) ($1528.74) 62- Solid wste depot (More than 5 000 tonnes per year) ($1358.88) 63 - Class I inert landfill site (More than 50 000 but not more than 500 000 tonnes per year) ($2717.76)

Sub total $ 13,588.82

Discharges to air, onto land, into waters

Proposed licehce fee: Part 3 Discharges to air (see Part 3 of Schedule 4 ofthe Environmental Protection Regulations 1987)

Discharges to air Discharge Discharges to air Discharge quantity quantity

Carbon monoxide 5250 g/min Nickel 0.1107 g/min

($2494.56) ($0.00)

Oxides of nitrogen 867 g/min Vanadium

($41212.90)

Sulphur oxides 404 g/min Zinc 0.03875 g/min

($28806.25) ($0.00)

Particulates (PM1o and PM2.5) 30 g/min Vinyl chloride

($2139.08)

Volatile organic compounds 19.74 g/min Hydrogen sulphide

($937.95)

Inorganic fluoride Hydrogen Benzene carbon oxysulphide Fluoride (2.07 g/min) ($244.42)



Aluminium Carbon disulphide

Arsenic 0.00171 g/min Acrylates ($0.00)

Chromium 0.0186 g/min Beryllium ($0.00)

Cobalt 0.00126 g/min Cadmium 0.000737 ($0.00) g/.min

($0.00)

Copper 0.01767 g/min Mercury 0.002964 g/min ($0.00) ($0.00)

Lead 0.00066 gfmin TDI (toluene-2, ($0.00) 4-di-iso-cyanate)

Manganese 0.08253 g/min MDI (diphenyl-methane ($0.00) di-lso-cyanate}

Molybdenum Other waste Benzene (2.25 g/min)

($106.91)

Subtotal $75,942.07

Proposed licence fee: Part 3 Discharges onto land or Into waters (see Part 3 of Schedule 4 of the Environmental Protection Regulations 1987)

Discharges onto land or into waters Discharge quantity

1. Liquid waste that can potentially deprive (a) biochemical oxygen demand (In receiving waters of oxygen (for each kilogram the absence of chemical oxygen discharged per day}- demand limit)

{b) chemical oxygen demand (in the absence of total organic carbon limit)

(c) total organic carbon

2. Biostimulants (for each kilogram discharged (a) phosphorus per day)-

(b) total nitrogen

3. Liquid waste that physically alters the (a} total suspended solids (for each characteristics of naturally occurring waters- kilogram discharged per day)

(b) surfactants (for each kilogram discharged per day) •

(c) colour alteration (for each platinum cobalt unit of colour above the ambient colour of the waters in each megalitre discharged per day)

(d) temperature alteration (for each 1 oc above the ambient temperature of the waters in each mega litre discharged per day) -

(i) In the sea south of the Tropic of Capri com

(II) In other waters

4. Waste that can potentially accumulate in the (a) aluminium, arsenic, cadmium, environment or living tissue (for each kilogram chromium, cobalt, copper, lead, discharged per day) - mercury, molybdenum, nickel,

vanadium and zinc



(b) pesticides

(c) fish tainting wastes

(d) manganese

5. E coli bacteria as Indicator species (In each (a) 1 000 to 5 000 organisms per 100 mega litre discharged per day) - ml

(b) 5 000 to 20 000 organisms per 100ml

(c) more than 20 000 organisms per 100ml

6. Other waste (per kilogram discharged per (a) oil and grease day)-

(b) total dissolved solids 17,060 kg/day

($40,547.41)

(c) nuoride

(d) Iron

(e) total residual chlorine

(f) other

Subtotal $ 40,547.41

Information and data used to calculate proposed fees

The detailed calculations of fee components, Including all Information and data used for the calculations are provided In the specified annexures to this application.

Proposed fee for works approval Annexure No

Details for cost of works

Proposed fee for licence Annexure No

Part 1: Premises NA

Part 2: Waste types Attachment 10.1

Part 3: Discharges to air, onto land, Into waters Attachment 10.2, 10.3 & 10.4

Prescribed fee for clearing permit (only required If clearing deviates or extends from that proposed In works approval or licence application)

Please indicate the clearing permit application fee

Area Permit:

0 $50 for an area of less than one hectare

0 $100 for an area between one hectare and 10 hectares

0 $200 for an area of more than 10 hectares

Purpose Permit:

0 A $200 fee Is required for all purpose pem1it applications



t

Attachment 11 : Request for exemption from publication

Information which you consider should not be published on the grounds for claiming exemption In accordance with Schedule 1 to the Freedom of Information Act 1992 must be specified in this Attachment.

NOT FOR PUBLICATION IF GROUNDS FOR EXEMPTION ARE DETERMINED

Section (x):

Guideline and appl ication form for applications (March 2016 V3) 14


Section Ground for claiming exemption: [x]:


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