1

Requestto amend a hazardous substance approval

Name of the approval to be amended:
Date:

June 2016

1

Requestto amend a hazardous substance approval

Important

This form is used to requestan amendment to an existing approval for ahazardous substance. An approval can be amended if the proposed change is considered to be minor in effect, or if it corrects a minor or technical error (see definitions below). More substantial changes to the existing approval will require the substance to be reassessed.

You can use this form to request an amendment(s) to a:

  • release approval (approved under sections 28A or 29 of the HSNO Act)
  • containment approval (approved under section 32 of the HSNO Act)
  • permission (granted under section 95A of the HSNO Act)
  • group Standard approval (issued under section 96B of the HSNO Act).

Please note that the Environmental Protection Authority (EPA) is not under any statutory obligation to make the change that you request.Also,please note that this form or its contents may be made publicly available, so any confidential information must be collated in a separate appendix labelled ‘confidential appendix’.

Is this the right form for you?

If the proposed amendment is not minor or to correct a technical error,or if you would like a substance to be completely re-evaluated, revoked or banned,then you should apply for “grounds for reassessment” instead of applying for an amendment.All forms are available on our website.

Do you need further assistance?

If you need help to complete this form, please go to our website ( or email us at .

Fees and charges

The fee for this application will depend on the complexity of the change being requested and the type of approval being amended. We will review your application and advise you of the fee before it is formally accepted and processed. Further information on our fees is available on the EPA website.

Definitions

The following definitions are provided as guidance only

Minor in effect / An amendment that does not create any changes to the residual risk – i.e., the risk that any reasonable person would consider acceptable after applying the controls.
An amendment that is minor in effect must also not result in changes to the financial costs of using and complying with the approval.
Minor error / An error that does not result in a different decision being made or affect the way the risk assessment was approached.
Technical error / A drafting or similar error.
1.Applicant details
1.1.Applicant

Company name:

Contact name:

Job title:

Postal address:

Physical address(provide only if not the same as the postal):

Phone (office and / or mobile):

Fax(if applicable):

Email:

1.2.New Zealand agent or consultant (if applicable)

Not applicable

Company name:

Contact name:

Job title:

Postal address:

Physical address(provide only if not the same as the postal):

Phone (office and / or mobile):

Fax(if applicable):

Email:

1.3.Formal correspondence contact
All formal correspondence will be sent to the contact person identified here

Applicant OR

Consultant OR

Company name:

Contact name:

Job title:

Postal address (provide only if not the same as the physical):

Physical address(provide only if not the same as the postal):

Phone (office and / or mobile):

Fax(if applicable):

Email:

1.4.Invoice contact
Complete this section only if the invoice contact is different to1.3. Formal correspondence contact – the invoice will be sent to the invoice contact

Same as applicant OR

Same as New Zealand Agent or consultant OR

Company name:

Contact name:

Job title:

Postal address (provide only if not the same as the physical):

Physical address:

Phone (office and / or mobile):

Fax(if applicable):

Email:

2.Which hazardous substance approvaldo you wish to amend?
Hazardous substance name / Approval number (e.g. HSRXXXXXX)

(Add more rows if required)

3.Whatspecific amendment(s) do you propose?
Where relevant, please include the current and proposed text, page or paragraph numbers,hazardous properties or control codes.
4.Why do you wish to amend this hazardous substance approval?
5.Describe why you believe the proposed amendment isminor in effect, or is needed to correct a minor or technical error
6.List any appendicesor reference material and provide a glossary (if required)
7.Signature of the applicant or the person authorised to sign on behalf of the applicant
☐ / I am making this application, or I am authorised to sign on behalf of the applicant or applicant organisation.
☐ / I have completed this application to the best of my ability and, as far as I am aware, the information that I have provided in this application form is correct.

Signature Date

June 2016