Form 10 − APPLICATION/RENEWAL
LICENCE TO CARRY OUT MINING OR MINERAL PROCESSING
(Section 24, Radiation Protection and Control Act 1982)
Indication of whether a new application, or a renewal
If a renewal, please indicate:
Date of invitation to renew
Licence number
Licence expiry date
Applicant’s details
Company business name
Company trading name
or Individual owner: Title
Surname
Given names
ABN
ACN
Principal business activity
If you are operating as a company, your summary from the ASIC website must be submitted with this
application.
Correspondence address
Suburb
Post code
Location of mine or mineral processing operation
Responsible person details (owner or person with authority to act on behalf of owner)
Title
Surname
Given names
Position title
Email address (work)
Telephone number (work)
Mobile number (work)
Mine Manager details (if different to responsible person)
Title
Surname
Given names
Position title
Email address (work)
Telephone number (work)
Mobile number (work)
OFFICE USE ONLY
Amount $
Date
Owner no
/
/
Licence no
Receipt no
RMP submitted
Condition
/
/
Full approval
/
/
by
Other supporting documentation
Source registration form(s) RSI 
Requested
/
/
by
Received
/
/
by
Updated July 2017
RWMP 
SSP 
STSP 
Other 
HUB
/
/
Processing Manager details
Title
Surname
Given names
Position title
Email address (work)
Telephone number (work)
Mobile number (work)
Radiation Safety Officer details
Title
Surname
Position title
Given names
Email address (work)
Telephone number (work)
Mobile number (work)
Type of operation
Nominate type of activity that relates to the type of operation being conducted under this licence (see
section below ‘Fees to be Paid’):
Supporting documents
Documents to be attached to the application:
Company summary from the ASIC website
Draft radiation management plan
Draft radioactive waste management plan
As appropriate, radiation source register, source security plan, source transport security plan, proposed
radiation source details
Please indicate if you are lodging your RMP at the time of application Yes
No
For information on what is to be included in an RMP and any supporting documentation you may be required to
submit, please review http://www.epa.sa.gov.au/business_and_industry/radiation/faqs
Declaration
I declare that the information provided on this form and in support of this application is to the best of my
knowledge complete and true in every particular.
Applicant’s signature
Title
Surname
Date
Given names
PENALTY FOR PROVIDING FALSE INFORMATION: UP TO $10,000
NOTE: This form does not constitute a legal application unless it has been properly completed
and signed, and is accompanied by the appropriate fee.
Notes
1
Failure to renew your licence by the expiry date will result in your licence lapsing, and may require a
new application to be made and payment of the applicable fees.
2
Changes to particulars since previous application must be provided as part of the renewal
application.
Updated July 2017
2
Fees
The following fees apply after 30 June 2017 and before 1 July 2018. GST Exempt
For a licence under section 24 of the Act to carry out mining or mineral processing
$10,611
Application fee (only payable on initial application for a licence)
Annual fee:
(i)
(ii)
for a licence authorising, at a site, operations for the mining or processing of
radioactive ores involving in situ leaching
$286,379
for a licence authorising, at a site, operations for the mining or processing of
radioactive ores (other than activities involving in situ leaching):
(A)
(B)
(C)
with a capacity to extract or process up to 5 megatonnes of
radioactive ore per year
$349,483
with a capacity to extract or process more than 5 megatonnes but
not more than 15 megatonnes of radioactive ore per year
$689,960
with a capacity to extract or process more than 15 megatonnes of
radioactive ore per year.
$930,400
(iii)
for a licence authorising, at a site, mineral sands operations
$27,113
(iv)
for a licence authorising, at a site, mineral processing operations where a
radioactive substance is generated as a byproduct.
$10,611
Lodgement of form and payment of fees
This form can be lodged by post to:
Or lodged via fax: (08) 8124 4671
Environment Protection Authority
Radiation Protection Branch
GPO Box 2607, ADELAIDE SA 5001
Email: [email protected]
Cheques should be made payable to: Environment Protection Authority
For credit card payment please complete the details below
Cardholder’s name
Visa
MasterCard
Card no
Amount of payment $
Telephone no
Cardholder’s signature
CVV No (back of card)
Credit card payment only accepted within agreed trading terms
NOTE: The EPA does not have the facility to handle cash payments
Enquiries
Radiation Licensing Officer
Tel:
8463 7826
Email: [email protected]
Environment Protection Authority
ABN 85 393 411 003
This licence is GST exempt
Updated July 2017
3
Expiry date
Amex