Form Use this form to report an allegation of non-compliance with Australia’s national environment laws Are you submitting this form as an individual, representative of an organisation or anonymously? Individual Organisation Anonymous Have you previously reported this matter? Yes No Date reported Reported to Reference Number (if applicable) Your contact details Your name Your email address If you would like National EPA to contact you about your report, please provide an email address that we can use to contact you. Your telephone number Your mobile phone Your organisation details (if submitting on behalf of an organisation) Type of incident What does this matter concern? Hazardous waste Heritage sites Wildlife trade Land clearing Ozone Sea dumping Threatened ecological community/species Underwater heritage sites Illegal logging Illegal export of waste tyres, waste glass, waste plastic Other (please specify) Hazardous Waste What hazardous waste commodity does this involve? Asbestos Biomedical and healthcare Chemical wastes generated by industries Dismantling ships E-waste (electronic wastes e.g mobile phones, computers) Mercury Obsolete pesticides Other Poly chlorinated biphenyls Used lead acid batteries Used oils What activity does this matter involve? Concealing hazardous waste False declaration concerning import, export, transport or disposal Export without a permit Import without a permit Mislabelling hazardous waste Other Transport without a permit Unsafe disposal of hazardous waste Unsafe transport of hazardous waste Heritage What type of heritage site does this matter involve? Commonwealth heritage National heritage Unknown World heritage (Australian property) Name of heritage site Wildlife Trade What type of wildlife does this matter concern? Fauna (animals) Flora (plants) Both What species is involved? Is the species alive? Yes No I do not know What activity or activities does this matter involve? Importing Exporting Possession Trading Land Clearing Does this matter involve a threatened ecological community? Yes No I do not know What threatened ecological community is involved (if known)? Does this matter involve a threatened species of fauna or flora? Yes No I do not know What threatened species of flora or fauna is involved (if known)? What is the size estimate of the land clearing area? Has the action commenced? Yes No I do not know Has a referral been submitted? Yes No I do not know What is the referral type (if known)? Controlled action Not controlled action Not controlled action – prescribed manner What is the referral number (if known)? What is the referral date? Has an approval been issued? Yes No I do not know What is the approval number (if known)? What is the approval date (if known)? Ozone What ozone depleting substances or synthetic greenhouse gas emissions does this matter involve? Aerosols Air conditioning Fire protection Foam blowing Medical Other Refrigeration Unknown veterinary What activity does this matter involve? Discharge Disposal Manufacture Import Export Unknown Use Sea dumping What waste or pollution does this matter involve? Ballast Burial at sea Other Unknown What was the source of the dumping at sea? Aircraft in Australian waters Australian aircraft outside Australian waters Australian vessel outside Australian waters Platform in Australian waters Vessel in Australian waters Unknown Threatened ecological community/species Does this matter involve a threatened ecological community? Yes No I do not know What threatened ecological community is involved (if known)? Does this matter involve a threatened species of fauna or flora? Yes No I do not know What threatened species of flora or fauna is involved (if known)? Underwater heritage What type of underwater heritage site does this matter involve? Australian relevant heritage site outside Australian waters Australian shipwreck outside Australian waters Australian sunken aircraft outside Australian waters Shipwreck in Australian waters Sunken aircraft in Australian waters Unknown What activity does this matter involve? Conduct causing adverse impact on protected heritage Looting Possession of permit-expire relics (artefacts) Possession of previously unnotified relics (artefacts) Prohibited conduct in a protected zone Selling heritage site artefacts Trading heritage site artefacts Unknown Illegal logging Type of product? Wood in the rough, sawn or chipped Wood articles e.g. building materials (sheets, plywood, densified wood, joinery), wooden frames, casks/barrels, Cartons, boxes, bags etc made of paper, paperboard and cellulose Wood pulp Paper products e.g. toilet and facial tissues, envelopes and notebooks Furniture Prefabricated buildings Unprocessed Australian logs Other (please specify) If other, please specify If other, please specify Details of incident Does a permit exist? Yes No I do not know Has the incident already occurred? Yes No I do not know What date did / when will it happen What time did / when will it happen? What date did / when will it happen: Date What date did / when will it happen: Time Where did it happen / where will it happen? (Location) Name of company/persons that may be involved Address of company/person if known Telephone of company/person if known Email address of company/person if known Other details of company/person if known For example: - ABN - Vehicles, vessels or aircraft that may be involved Details of problem – please be as specific as possible Source of information e.g. social media or company’s website (please insert URL to webpage), word of mouth or item located in store (please provide name and location of store) Do you have any documents, photos, audio or video files relevant to this matter? Yes No If your file is over 2MB or you have more than 2 files, an officer will be in contact with you to request the information. Please ensure you have given your contact details. Upload file Maximum 2 files.40 MB limit.Allowed types: gif jpg jpeg png txt pdf doc docx xls xlsx. Acknowledgement By submitting this form, I declare that the information provided by me is true and correct to the best of my knowledge and beliefs. Cards Section
