General Information
Who is excavating or otherwise generating the material?
Company Name
*
Company Representative
*
First Name
Last Name
Position
*
Owner
Director
Manager
Supervisor
Employee
Other
Other - Please Specify
*
Address
*
Street Address
Street Address Line 2
Suburb
State
Post Code
Phone Number
*
-
Area Code
Phone Number
Email
*
Confirmation Email
example@example.com
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Source Site Information
Details regarding site of origin of excavated or otherwise generated material. This waste type consists of soil (being clay, silt and/or sand), gravel and rock of naturally occurring materials. Fill material, often referred to as ‘clean fill’ by industry, may be suitable for site filling or levelling depending on an assessment of contaminant levels and intended use.
Site Name (Optional)
Site/Project Name
Site Address
*
Street Address (include lot/street number)
Street Address Line 2
City
State / Province
Postal / Zip Code
Volume of material to be excavated?
*
m3
Purpose of excavation?
*
Have there been any demolition activities on site?
*
Yes
No
Please specify
*
Has there been any asbestos found or removed on site or is the source site listed on the EPA Priority Sites Register or been issued a Clean Up Notice by EPA?
*
Yes
No
Please specify
*
Upload Clearance Certificate
*
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Maximum 20Mb
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General Fill Information
Refers to Source Site generating fill.
How is the fill generated?
*
Natural Ground
Previously Imported Fill
Do you have any environmental audit reports and/or a site assessment for its origin?
*
Yes
No
Would you like to upload any or all of these reports/assessments?
*
Yes
No
Upload Report
*
Choose File...
Multi-file upload available.
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Land Use
What is the previous and current use of the land. Select all that apply.
Previous Land Use
*
Chemical Storage
Commercial
Farming (Ex material from fuel tanks/chemical storage, sheep dips or similar)
Fuel Storage
Filling (Imported Soil)
Manufacturing
Market Gardens
Parks
Processing
Recycling
Residential Sites / Sub divisions
Schools
Treatment
Underground storage tank (if recently installed & no evidence of leaks)
Waste Disposal
Other
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Current Land Use
*
Chemical Storage
Commercial
Farming (Ex material from fuel tanks/chemical storage, sheep dips or similar)
Fuel Storage
Filling (Imported Soil)
Manufacturing
Market Gardens
Parks
Processing
Recycling
Residential Sites / Sub divisions
Schools
Treatment
Underground storage tank (if recently installed & no evidence of leaks)
Waste Disposal
Other
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Field Assessment
In order to fill out soil declaration, you must physically inspect the site
Does the material contain any of the following?
*
Category A, B, C or D prescribed industrial waste
Acid sulphate soil
Acid sulphate rock
None of the above
Does this material have an odour, or any discolouration or staining?
*
Yes
No
What is the ground cover?
*
Grasses
Building or Structures
Bare Soil
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Are there above or below ground tanks?
*
Yes
No
Is the site close to industrial sites?
*
Yes
No
Is your material extremely wet? (Slurry- mixture of soil & water)
*
Yes
No
Are any of the following present on or within the fill material?
*
Industrial waste such as concrete, brick, asphalt, plastics, metal or wood
Organic matter
Household/Domestic waste
None of the above
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Further Documentation
Do you have any other photos, files or documents you would like upload, which may assist us with your site assessment?
*
Yes
No
Upload
*
Choose File...
Multi-file upload available.
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Site Information
Nominated Landfix Site
*
Batey Court Bulla
Other
Other - Please Specify
*
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Terms & Conditions
Please read the following terms and conditions carefully.
I understand and agree.
*
Landfix maintains the right to refuse or reject any material that it believes does not come from the nominated site of origin or does not meet the current EPA requirements and guidelines.
I declare.
*
I am the fill generator or have been appointed by the fill generator to complete this form on their behalf and apply to dispose of the fill at the fill site nominated below. I understand that Landfix maintains the right to refuse or reject the material that it believes does not originate from the nominated site or does not meet the required EPA standards.
I acknowledge, understand and agree.
*
By submitting this form I warrant on behalf of the generator that all fill material to be disposed of by the generator will come exclusively from the nominated site of origin. The generator indemnifies Landfix Pty Ltd against all costs that may be incurred as a result of having to remove any materials that do not meet the specifications for 'Fill Material' as specified by EPA Publication IWRG702, EPA Victoria Publication 1828.3 and subsequent revisions. The indemnity includes but is not limited to cost associated with the plant and machinery hire, disposal fees, labour, loss of income through site closures. I acknowledge that acceptance of 'Fill Material" is solely at the discretion of Landfix Pty Ltd and maintains the right to reject any material that it believes does not originate from the nominated site or does not meet the required EPA standards.
I acknowledge, understand and agree.
*
I certify that the Industrial Waste described within this form and the information provided to Landfix Pty Ltd relating to this waste, meets the requirements of “Fill” material and is suitable for disposal as such, under the Victorian EPA’s waste determination, made under Regulation 5(3)(a) of the Environment Protection Regulations 2021.
Signature
*
Full Name
*
First Name
Last Name
Date
*
/
Day
/
Month
Year
Date
Submit
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