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Notification of Schedule 11 Hazardous Chemicals
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Notification of Schedule 11 Hazardous Chemicals
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Application Information

Notification of Schedule 11 Hazardous Chemicals
Fields marked with * are required

Application Information

Notification of Schedule 11 hazardous chemicals This form is to be used by the person conducting a business or undertaking (PCBU) at a workplace to notify SafeWork NSW when: 1.Hazardous chemicals are used, handled or stored at the workplace in quantities that exceed manifest quantities, as specified in column 5 of table 11.1 of Schedule 11 of the WHS Regulation. 2.A notification to the Resources Regulator for Mine and Petroleum sites. 3.There will be a significant change to a current notification record in the risk of using, handling or storing the Schedule 11 hazardous chemicals. A significant change includes: a change to the quantity, location or manner of storage of chemicals, or when the affected chemicals are of a quantity greater than the placard quantity for that chemical or group of chemicals. 4.A new owner and/or PCBU has taken control of a site. 5.Requesting a closure of record or when hazardous chemicals no longer exceed manifest quantities, as specified in column 5 of table 11.1 of Schedule 11 of the WHS Regulation, or cease to be used, handled or stored at the workplace. 6.There is abandonment of an underground tank, partially underground, or fully mounded tank that was used to store flammable gases or flammable liquids. 7.There is a need to change contact details, or emergency contact details. 8.Your notification certificate is lost, stolen, damaged, not received or if there was a printing error.

Google Places

The address search fields in this form use Google Places to help fill in the address details. By using this feature you agree to be bound by Google's Terms of Service and are subject to Google's Privacy Policy.

Privacy Compliance Statement

This information is collected by SafeWork NSW for the purposes of undertaking the evaluation, assessment and processing of a notification of Schedule 11 hazardous chemicals, as required by the WHS Act and WHS Regulation. This information may also be used by SafeWork NSW for the purposes of confirming applicant details, to establish and maintain an internal and external database and to assist SafeWork NSW and its inspectorate with its work generally. This information may also be used by the Resources Regulator. It may also be provided to other state, territory and the Commonwealth regulatory authorities. Except for the purposes of prosecution and unless such disclosure is otherwise required by law, the information will not be accessed by other third parties in a way that would identify the individual without the consent of that individual. You may also apply to SafeWork NSW to access and correct any information about yourself that SafeWork NSW holds if that information is inaccurate, incomplete, not relevant or out of date. Applications should be made in writing to: Privacy Contact Officer,
SafeWork NSW,
Locked Bag 2906,
Lisarow NSW 2252.

Type of Notification

Notification of Schedule 11 Hazardous Chemicals
Fields marked with * are required

Notification Type

Please select the type of notification you are making: *
Type of Amendment *
Please select all that apply.

Application Details

Notification of Schedule 11 Hazardous Chemicals
Fields marked with * are required

Contact Person

Business Name/Person Conducting Business or Undertaking (PCBU)

of 100 characters

Site Address

Address of the business or undertaking where Schedule 11 hazardous chemicals exceeding manifest quantities are to be used, handled or stored.
WHS (Mines and Petroleum Sites) Act 2013
Is this a mine or petroleum site regulated by the NSW Resources Regulator?
Is the PCBU as entered above the Mine Operator or Petroleum Site Operator?
Mine or Petroleum Site Operator

Old Street Address (must NOT be PO Box)

Street Address (must NOT be PO Box)

Enter the site address into the Street Address search field and make a selection from the list to pre-populate the address fields. If the address does not appear in the results, you must enter the address in fields provided below.If you do not know the Latitude and Longitude coordinates, leave these fields blank.
Site address
This widget uses Google Places. In order to use it you need to comply with the Google Place API Policy.To summarise

Your Terms of Use and Privacy Policy must be publicly available.You must explicitly state in your applications Terms of Use that by using your application, users are bound by Google’s Terms of Service.You must notify users in your Privacy Policy that you are using the Google Maps API(s) and incorporate by reference the Google Privacy Policy.
Once you have complied with Google's policy you should hide this note.

Nearest Cross Street

of 100 characters

Postal Address

Same as Street Address? *

Previous Occupiers Details

Notification of Schedule 11 Hazardous Chemicals
Fields marked with * are required

Previous Occupiers Details

If this is a new notification (e.g. a new PCBU), for a site with existing hazardous chemicals that exceed manifest quantities, provide the previous PCBU details if known.
of 100 characters

Hazardous Chemicals

Notification of Schedule 11 Hazardous Chemicals
Fields marked with * are required

Emergency Details

Emergency Contact 1

Emergency Contact 2

Manifest Prepared

Please provide the date the manifest was last amended or, if it has not been amended, the date it was prepared. *

Goods too Dangerous to be Transported

Please note: for a significant change amendment, please only provide details of the hazardous chemicals that are affected by the change.

Dangerous Good

Units *
Units

Listing of Hazardous Chemicals Used, Stored or Handled

Please provide details of all hazardous chemicals that are above placard quantities. Please note: for a significant change amendment, please only provide details of the hazardous chemicals that are affected by the change.

Chemical

UN Number *
Note: If you are notifying Diesel or any other Combustible Liquid C1, please enter 00C1 in the UN number field.
Enter and select a number in the UN Number field and then select the Lookup button.
of 200 characters
Packing Group
Units *
Units *
Diameter of fixed vertical tanks used to store fire risk hazardous chemicals (m)

Abandonment of Tank

Notification of Schedule 11 Hazardous Chemicals
Fields marked with * are required

Abandonment of Tank

Please ensure all site documentation such as manifest, emergency plans, hazardous chemicals registers have been updated to reflect the changes as a result of the tank abandonment.

Abandonment of Tank

Units *
Please provide either the UN Number or Previous Contents. *
UN Number *
Note: If you are notifying Diesel or any other Combustible Liquid C1, please enter 00C1 in the UN number field.
of 250 characters
Please provide either Class ADG code or GHS category of the chemical the tank contained. *
Has the abandoned tank been removed? *
of 250 characters

Replacement

Notification of Schedule 11 Hazardous Chemicals
Fields marked with * are required

Replacement

of 1000 characters

Lodgement Fees

Notification of Schedule 11 Hazardous Chemicals
Fields marked with * are required

Lodgement Fees

Description
GST
Price
Please confirm your preferred method of payment *
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You will be redirected to another page to enter your credit card details, later in this process. Click on the continue button.
Please contact your Bank or Financial institution to make this payment. Your notification will not be considered complete until the payment is processed by the bank and notified to SafeWork NSW. There may be a delay of up to 2 working days before SafeWork NSW processes the payment. The biller code and customer reference number are available in the Save & Print function - download copy of your submitted form (at the end of this process), click on the Continue button.

Applicant Declaration

Notification of Schedule 11 Hazardous Chemicals
Fields marked with * are required

Applicant Declaration

I, , declare that: I am 18 years of age or over I have authority from the PCBU (if applicable) to lodge this application The information in this notification is true and correct to the best of my knowledge I consent to SafeWork NSW making enquiries and exchanging information with work health and safety regulators in other states, territories of the Commonwealth regarding any matter relevant to this application

Invoice

Notification of Schedule 11 Hazardous Chemicals
Fields marked with * are required
SafeWork NSW
ABN: 81 913 830 179
92-100 Donnison Street
Gosford NSW 2250
TAX INVOICE Date:
Reference Code:
Receipt Number:
Details
Amount
If you have any questions regarding this invoice, please contact SafeWork NSW on 13 10 50.
SafeWork NSW
ABN: 81 913 830 179
92-100 Donnison Street
Gosford NSW 2250
TAX INVOICE Date:
Reference Code:
Receipt Number:
Details
Amount
If you have any questions regarding this invoice, please contact SafeWork NSW on 13 10 50.
Biller Code: 768739
Ref:
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this payment from your cheque, savings, debit,
or transaction account. More info: www.bpay.com.au