Form Wildlife management Exempt clearing notification (protected plants) This form is to be used to notify the Department of Environment and Heritage Protection (EHP) of proposed clearing of protected plants that is exempt under section 261ZA of the Nature Conservation (Wildlife Management) Regulation 2006. Important information A protected plant clearing permit is required for clearing protected plants in an area identified as high risk on the flora survey trigger map, unless an exemption applies. This form is to be used to notify EHP of proposed clearing that is exempt from the requirement of a permit under section 261ZA of the Nature Conservation (Wildlife Management) Regulation 2006. Under section 261ZA, a person may take a protected plant if a flora survey report is submitted to the chief executive which provides evidence that endangered, vulnerable or near threatened plants are not present in a clearing impact area, or if these plants are present, that the proposed clearing will avoid the plants by at least 100m. Section 261ZA requires that the flora survey report will be provided at least 1 week before the person starts clearing, but no later than 12 months after the flora survey was undertaken. The person giving this notification will receive confirmation of receipt by EHP. Clearing under this exemption must be conducted within two years after the flora survey report is submitted. Information you provide in this notification form is required for departmental assessment, compliance and monitoring purposes. Please refer to the privacy statement at Part 7 of this form. 1. Information regarding the person giving this notification The chief executive (or their delegate) may use information provided under Parts 2 and 3 to assist in determining whether they are satisfied that an applicant is a suitable person (s25, Nature Conservation (Administration) Regulation 2006). Part 3 applies only to a corporate body with an office in Queensland. Please tick the appropriate box: AN INDIVIDUAL Complete Section 2 applicant details — then complete sections 4 to 7 A CORPORATE BODY Complete Section 3 applicant details — then complete sections 4 to 7 2. Details for an individual FAMILY NAME TITLE GIVEN NAME/S DATE OF BIRTH RESIDENTIAL ADDRESS (NOT A POST OFFICE BOX) POST CODE TELEPHONE (BUSINESS HOURS) MOBILE Page 1 of 5 • NCS/2016/ 2535 • Version 1.02 • Effective: 23 December 2016 FACSIMILE ABN 46 640 294 485 Form Exempt clearing notification (protected plants) TELEPHONE (AFTER HOURS) EMAIL POSTAL ADDRESS (WRITE ‘AS ABOVE’’ IF SAME AS RESIDENTIAL ADDRESS) POST CODE 3. Details for a corporate body REGISTERED LEGAL ENTITIY NAME OF THE CORPORATE BODY (NOT A BUSINESS TRADING NAME) TRADING NAME/S OF THE CORPORATE BODY (IF APPLICABLE) REGISTERED BUSINESS ADDRESS OF THE CORPORATE BODY (NOT A POST OFFICE BOX) POST CODE TELEPHONE NUMBER OF THE CORPORATE BODY (BUSINESS HOURS) FACSIMILE NUMBER OF THE CORPORATE BODY EMAIL ADDRESS OF THE CORPORATE BODY WEBSITE URL OF THE CORPORATE BODY POSTAL ADDRESS OF THE CORPORATE BODY (WRITE ‘AS ABOVE’ IF SAME AS BUSINESS ADDRESS) POST CODE ABN / ACN / AN, OR TITLE AND SECTION OF LEGISLATION UNDER WHICH THE CORPORATE BODY HAS LEGAL STATUS NAME OF A DIRECTOR OR EXECUTIVE OFFICER OF THE APPLICANT CORPORATE BODY SIGNATURE OF A DIRECTOR OR EXECUTIVE OFFICER OF THE APPLICANT CORPORATE BODY DATE Details of the person nominated to be in charge of the place(s) where the authorised activity is to be undertaken NOMINATED PERSON’S FAMILY NAME NOMINATED PERSON’S TITLE NOMINATED PERSON’S GIVEN NAME/S NOMINATED PERSON’S DATE OF BIRTH NOMINATED PERSON’S RESIDENTIAL ADDRESS (NOT A POST OFFICE BOX) POSTCODE NOMINATED PERSON’S TELEPHONE NUMBER (BUSINESS HOURS) NOMINATED PERSON’S MOBILE NUMBER NOMINATED PERSON’S TELEPHONE NUMBER (AFTER HOURS) NOMINATED PERSON’S EMAIL ADDRESS NOMINATED PERSON’S POSTAL ADRESS (WRITE “AS ABOVE” IF SAME AS RESIDENTIAL ADDRESS) Page 2 of 5 • NCS/2016/ 2535 • Version 1.02 • Effective: 23 December 2016 NOMINATED PERSON’S FACSIMILE NUMBER POSTCODE Department of Environment and Heritage Protection Form Exempt clearing notification (protected plants) 4. Where is the clearing to be conducted? Please identify area type: Provide the street address or real property description(s) of the land(s) in which the project is located, and the local government area. (If you require more space, attach a separate sheet.) STREET ADDRESS/RPD LOT PLAN LOCAL GOVERNMENT AREA If possible, provide a specific location within the property, a property name or attach a map with the project area clearly delineated. Also include the map name/details. SPECIFIC LOCATION/PROPERTY NAME GEOGRAPHICAL COORDINATES 5. What are the approximate start and completion dates for the project? NOTE: 1. The flora survey report must be provided at least 1 week before clearing commences. 2. The flora survey must have been undertaken within the previous 12 months from the date of this notification. START DATE END DATE 6. Flora survey requirements 6.1 Flora survey Has a flora survey been undertaken in the proposed clearing area? NO If no, STOP – a flora survey is a requirement of s261ZA and must be undertaken if you propose to proceed. Please contact a Wildlife officer at your nearest regional EHP office. YES If yes, was the flora survey undertaken in accordance with the flora survey guidelines1? YES If yes, go to section 6.2 (Results of flora survey), below. NO If no, was the flora survey undertaken in accordance with an alternative flora survey methodology that has been agreed to by the chief executive? YES If yes, please attach to this notification your evidence of the chief executive’s agreement. Go to section 6.2 1 See section 253, Nature Conservation (Wildlife Management) Regulation 2006 - the chief executive may, by gazette notice, approve or make guidelines (the flora survey guidelines) about the conduct of a flora survey. Page 3 of 5 • NCS/2016/ 2535 • Version 1.02 • Effective: 23 December 2016 Department of Environment and Heritage Protection Form Exempt clearing notification (protected plants) (Results of flora survey), below. NO If no, STOP – the alternative flora survey methodology must first be assessed – please contact a Wildlife officer at your nearest regional EHP office. 6.2 Results of flora survey Are endangered, vulnerable or near threatened plants present within the clearing impact area? NO If no, go to section 6.3 (Flora Survey Report), below. YES If yes, will clearing of, or damage to, these plants be avoided by at least 100m? NO If no, STOP – this exemption does not apply for this clearing activity and a clearing permit will be required to take protected plants. Please refer to the EHP website for protected plant clearing permit requirements. YES If yes, go to section 6.3 (Flora Survey Report), below. 6.3 Flora survey report WHEN WAS THE FLORA SURVEY UNDERTAKEN? PLEASE PROVIDE DATE/S: FLORA SURVEY REPORT COMPLETION DATE: Note: Under the Nature Conservation (Wildlife Management) Regulation 2006, the results of a flora survey are to be presented in a flora survey report, prepared in accordance with the flora survey guideline (or as otherwise agreed), within 12 months of the flora survey being undertaken. 7. Privacy statement Information you provide on this form is being collected by the Department of Environment and Heritage Protection to process and administer your exempt clearing notification (protected plants), pursuant to section 261ZA of the Nature Conservation (Wildlife Management) Regulation 2006. Some information may, if required, be provided to one or more of the Departments of National Parks, Sport and Racing; Agriculture and Fisheries; or Health in order to investigate any suspected unlawful activity, biosecurity or health issues. Information regarding the fact that you are exempt pursuant to section 261ZA of the Nature Conservation (Wildlife Management) Regulation 2006 may be provided to any party upon request. However, your personal information will not be disclosed to any other parties unless authorised or required by law. More information on our commitment to privacy is available on our website: http://www.ehp.qld.gov.au/legal/privacy.html. Page 4 of 5 • NCS/2016/ 2535 • Version 1.02 • Effective: 23 December 2016 Department of Environment and Heritage Protection Form Exempt clearing notification (protected plants) Declaration Note: If you have provided false or misleading information in this form you may be liable to prosecution under relevant Acts or Regulations. I do solemnly and sincerely declare that the information provided is true and correct to the best of my knowledge and I make this solemn declaration conscientiously believing the same to be true. I understand that all information supplied in or with this form may be disclosed publicly in accordance with the Right to Information Act 2009 and the Evidence Act 1977. NAME OF NOTIFYING PERSON - EITHER AN INDIVIDUAL, OR A DIRECTOR/EXECUTIVE OFFICER SIGNING FOR THE APPLICANT CORPORATE BODY SIGNATURE OF NOTIFYING PERSON DATE IF YOUR NOTIFICATION IS MADE ON BEHALF OF A CORPORATE BODY, PLEASE INDICATE YOUR POSITION IN THE CORPORATE BODY (DIRECTOR OR EXECUTIVE OFFICER) 8. Applicant checklist Notification form completed and signed Report of flora survey conducted in accordance with the flora survey guidelines attached, OR Report of flora survey, plus evidence of alternative flora survey methodology that has been agreed by the chief executive, attached Privacy statement acknowledged Please return your completed notification to: Customer Service Team Department of Environment and Heritage Protection GPO Box 2454 Brisbane Qld 4001 Enquiries: 1300 130 372 Facsimile: (07) 3330 5875 E-mail: [email protected] A copy of the Nature Conservation (Wildlife Management) Regulation 2006 may be obtained from the Office of Queensland Parliamentary Counsel website http://www.legislation.qld.gov.au A copy of the Protected Plants Code of Practice2, the Flora Survey Guidelines – Protected Plants and the Information sheet – Wildlife authorities and privacy may be obtained from the EHP website http://www.ehp.qld.gov.au/licences-permits/plants-animals or by contacting the EHP Referral Centre on 1300 130 372. 2 See Schedule 7, Nature Conservation (Administration) Regulation 2006 – Protected Plants Code of Practice means the document called ‘The code of practice for the harvest and use of protected plants’, approved by the chief executive under section 174A of the Nature Conservation Act and published on the EHP website. 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