Material Declaration 1Step 12Step 23Step 3 Generator Information (Company, Organization, business or Individual requiring the fill to be removed)Generator Name Generator Contact Name Position in Company Email PhoneCompany Address Suburb Postcode Source Site Details (The source site where the material you intend to import originated)Site Address Suburb Postcode Purpose of Excavation Estimated Volume Fill Generated FromVirgin GroundPreviously Imported FillCommercial BusinessFarmlandOtherDetails Other Information Please conduct a site inspection and answer the following questionsAre there any industrial sites bordering the source site? Yes No Has there been demolition activities on the site? Yes No To your knowledge has the source site ever been a landfill site? Yes No Does the material have any evidence of odour? Yes No Are there any signs of distressed vegetation that may indicate soil contamination? Yes No Is there any of the following materials at the source site? Yes No Category A ,B or C Material Yes No Industrial waste Yes No Asbestos Yes No Acid sulfate soil Yes No Solid Inert Waste Yes No PLEASE READ THE FOLLOWING CAREFULLY It is a site requirement that you agree and understand the following: EPA Victoria “Industrial Waste” Publication 1624 May 2016 states: “It is the responsibility of the Generator (Site Occupier) to” Ensure the fill material is not contaminated Identify an appropriately approved receiving facility for the soils Provide evidence to the receiving facility of the soil characterisation EPA does not regulates the use of fill material but Environment Protection Act 1970 requires the Generator to prevent adverse impacts on the receiving environmental and human health. SITE ASSESSMENT To comply with EPA requirements, soil may be classified as fill material, when An assessment will demonstrate that the material is not contaminated, or Contaminate levels are below those specified in IWRG621 Soil hazard categorisation and management (“Fill Material Upper Limits” shown in table 2 of EPA 1WRG621), or Any elevated levels of metals (such as Arsenic) or other constituents can be demonstrated to be of Natural origin. Where it can be demonstrated that the constituents of concern are naturally elevated. EPA does not consider these soils to be ‘contaminated’ and can therefore be classified to be fill material. EPA PUBLICATION IWRG621 CAN BE VIEWED AT: https://www.epa.vic.gov.au/-/media/epa/files/publications/iwrg621.pdf I certify that I have undertaken an assessment of the site and the materials being supplied in accordance with the EPA guidelines. Based on these investigations, I can confirm that:Consent The site of origin does NOT have the potential for contaminationConsent The site of origin DOES have the potential for contaminationNOTE: If option 2 is selected, then a site assessment report, prepared by a suitably qualified environmental professional, will be required to demonstrate compliance that the material qualifies as fill and is NOT contaminated.Consent A site/material assessment report for the material supplied is attached.Date(Required) DD slash MM slash YYYY Name of Signatory(Required) Signature(Required)ACKNOWLEDGEMENT BY GENERATOR By signing this form, I warrant on behalf of the Generator that all fill material that will be disposed of by the Generator at the FILL SITE will come solely from the specified source site address. The Generator indemnifies against all costs the receiver may incur associated with removal from the fill site of any materials that does not meet the specification for “fill material” as specified by EPA IWRG600.2, EPA “Industrial Waste” publication and subsequent revisions including, but not limited to Plant and Machinery hire, disposal fees, labour and loss of income through site closures. I acknowledge that the acceptance of “Fill Material” is solely at the discretion of the receiver at the FILL SITE and that the receiver maintains the right to reject any material that they believe has not generated from the nominated address of origin or does not meet the required EPA standards Δ
