Internal Job
Reference
TIPPING PRE-APPROVAL APPLICATION FORM
Tipping at Dirtworks Sites requires pre-approval. No loads will be accepted at the tip unless a truck carries a
tipping permit. Permits will only be issued once all information requirements are satisfied. All jobs placing more
than 200m3(solid) at Dirtworks tip sites will not be approved unless contamination testing results have been
provided. Dirtworks Tipping conditions apply. Please send this form to [email protected]
Section 1 – Applicant Details
Customer
…………………………………………………………………………….. (must be on-account)
Contact name
……………………………………………………………………………..
Purchase order/reference
……………………………………………..
(If you require a purchase order on your invoice, please supply a purchase order above. Dockets must have a P/O number or Tipping approval number for
Dirtworks to assign a P/O to an invoice)
Section 2 – Transporter details
Name
……………………………………………………………………………
Contact name
…………………………………………………………………………..
Contact number
………………………………………………………………………….
Transport dates
Start ……. / …….. / …….. Finish ……. / …….. / ……..
Section 3: Job Details
Volume of Fill (m³) ……………………………………….
Type of Job Site ………………………….…….
Source address…………………………………………………………………………………………………….
Type of fill
Top Soil
Concrete
Asphalt
Rock
(Tick as many as
apply)
Clay
Volcanic
Vegetation
Other…………………
………
Does the fill originate from
HAIL site
Consented contamination site
Auckland CBD
Past Land Use of Site
Residential
Horticultural
Industrial
(Tick all that apply)
Agricultural
Other ………………………………..
Does the material contain asbestos?
Yes
No
Has this material been assessed for the presence of contamination?
Yes
No
If yes above, have you attached the relevant reports/test results?
(results must be provided for jobs placing more than 200m3 at Dirtworks
sites)
Yes
No
Are these works associated with remediation of a contaminated site? (please describe)
…………………………………………………………………………………………………………………………………………
…………………………………………………………………………………………………………………………………………
Are there any known hazardous substances present in the material or safety and handling instructions?
…………………………………………………………………………………………………………………………………………
…………………………………………………………………………………………………………………………………………
Has the material been removed from site due to contamination or been rejected from another facility?
…………………………………………………………………………………………………………………………………………
Internal Job
Reference
Section 4: Terms and Conditions
Dirtworks tipping terms and conditions and our acceptance criteria are available on request, please email
[email protected] for a copy.
Information on HAIL sites can be found at http://www.mfe.govt.nz/land/risks-contaminated-land/my-landcontaminated/hazardous-activities-and-industries-list-hail
The Account Holder/Customer who is being invoiced for the fill material is responsible and liable for
ensuring that all fill material disposed at any of our sites is within the criteria/limits. If on-site testing results
show that material imported to site is not cleanfill but it is within our managed fill acceptance criteria, then
our managed fill prices will apply. Any fill material deposited at this site that does not meet the criteria or is
deemed unacceptable and is rejected by Dirtworks (at its sole discretion and at any time) will be removed
and the Account Holder/Customer accepts liability for all costs associated with removal of fill material from
Dirtworks site(s), including any tests required, and all direct and consequential or indirect losses that
Dirtworks may incur. The Account Holder/Customer agrees to fully cooperate with Dirtworks if any further
information or assistance is required in relation to the material delivered. Dirtworks is not liable to the
Account Holder/Customer in anyway if the fill material is rejected or needs to be removed from a Dirtworks
site for any reason.
Section 5: Declaration
The information provided is true and accurate. I have read and understood the tipping terms and conditions.
I have read and understood Section 1 to 4. I have authority to sign this document on behalf of the Account
holder/customer disposing of material at Dirtworks tip sites.
I understand that vehicles may not tip at Dirtworks tip sites unless the vehicle has a current permit to tip.
Name …………………………………………….
Signature ………………………………………….
Company ……………………………………….
Position…………………………………………….
Date ………………………………………………….
Section 6: Dirtworks Internal Section for Approval (OFFICE USE ONLY)
Material type:
Cleanfill
Managed fill
Landfill
Comments:
…………………………………………………………………………………………………………………
…………………………………………………………………………………………………………………
…………………………………………………………………………………………………………………
…………………………………………………………………………………………………………………
Tip site ……………………………………………….
Approved by……………………………………….
Date ………………………………………………….