Annual Hazardous Goods & Chemicals Declaration

Property: 11 Mary Street, Cygnet, Tasmania — CT Volume 167368 Folio 5

This declaration forms part of your occupancy agreement. It must be completed before occupation, on each anniversary, and whenever there is a proposed change to the type, classification, storage method or maximum quantity of any hazardous chemical.

Occupancy details

Tenant / Licensee legal name *

Trading name, if different

ABN

Occupancy / unit *

Email *

Phone

Declaration period starts *

Declaration period ends *

24-hour emergency contact

Name *

Mobile *

A. Nil declaration

I declare that no hazardous chemicals, dangerous goods, flammable liquids, gases, oxidisers, corrosives, toxic substances, explosives or other regulated substances are or will be used, handled or stored in the Premises, other than ordinary consumer products used in consumer quantities and in accordance with their labels.

If you tick this box, the hazardous chemical fields below will be disabled. Untick it if any regulated or hazardous substance is present or proposed.

B. Declared hazardous chemicals

State the largest quantity reasonably expected to be present. Use the product SDS to identify the hazard class/category and UN number where applicable.

C. Supporting documents and controls

Tick each item that is current and available. Where something is not applicable, leave it unticked and explain that in the notes field.

Current SDS for every listed hazardous chemical Hazardous chemical register Plan/photo showing storage location Evidence of placarding / manifest notification where applicable Fire, spill and emergency controls relevant to the chemicals Any licence, approval or authority required for the tenant's activity

Links to SDS / registers / plans / supporting documents, if available

Notes / items not applicable / additional information

D. Tenant certification

I certify that the information above is complete and accurate; the maximum quantities stated are the largest quantities reasonably expected to be present; I will not introduce a new hazardous chemical or exceed an approved maximum without prior written approval; I will immediately notify the Landlord or Manager of any incident, spill, fire, regulator notice or material change; and I will comply with all WHS, fire, environmental and other legal requirements.

I agree to and certify the declaration above. *

Typed full name / electronic signature *

Capacity / position *

Date *

Manager approval: The tenant's submission records the proposed maximum quantities. Any approved maximum is confirmed separately by the Landlord or Manager. Submission of this form does not itself constitute approval to introduce or increase hazardous goods.