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FORM WHSHCM002: NOTIFICATION FORMMANIFEST QUANTITIES SCHEDULE 11 CHEMICALS/ABANDONED (General Public Services)

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WHS-HCM002 September 2018
1
FORM WHS—HCM002
NOTIFICATION FORM—MANIFEST QUANTITIES
SCHEDULE 11 CHEMICALS/ABANDONED TANK
Please note the following information before starting your application
> Manifest notifications should be made by the person conducting the business or undertaking (PCBU) at a workplace
where Schedule 11 hazardous chemicals exceed the manifest quantity. When the PCBU in these circumstances, is the
Commonwealth, a public authority or a non-Commonwealth licensee, notification should be made to Comcare.
> For tank abandonment notifications, the notifier would be the PCBU with control or management of a tank at a
workplace. When the PCBU is the Commonwealth, a public authority or a non-Commonwealth licensee, the notification
should be made to Comcare.
> It is advised that all notifiers read the Guidance Material for Schedule 11 Hazardous Chemicals and Abandonment of Tanks
Notifications before completing this notification.
> The guidance material is available on the Comcare website under Safety & Prevention>Health & safety topics>Hazardous
chemicals.
> For more information call 1300 366 979 or email WHS.Chemicals@comcare.gov.au.
PRIVACY AND PERSONAL INFORMATION
Any personal information collected by Comcare in connection with this notification may be used in Comcare’s exercise of its
functions and powers under the Work Health and Safety Act 2011 (WHS Act), Work Health and Safety Regulations 2011 (WHS
Regulations) and other legislation, and the administration and evaluation of Comcare’s programs generally.
Comcare may disclose personal information to the following bodies and agencies, including but not limited to, its legal
advisers; the Safety, Rehabilitation and Compensation Commission; contractors and agents; a court or tribunal; state or
territory work health and safety regulatory agencies; Commonwealth, state or territory industry regulators; enforcement
agencies (including police investigating or conducting an interview in connection with the notification); state and territory
Coroners; and any other person where there is an obligation under law to do so.
Comcare and inspectors appointed by Comcare respect your privacy and are committed to protecting your personal
information. If you have any concerns about the privacy of your personal information, please contact Comcare’s privacy
contact officer by email at privacy@comcare.gov.au.
Comcare’s privacy statement is available at http://www.comcare.gov.au/about_us/privacy.
PCBUs IN COMCARE’S JURISDICTION
A PCBU must notify Comcare of their manifest quantities of Schedule 11 Chemicals or Abandonment of Tanks if the PCBU
is the Commonwealth, a public authority or a non-Commonwealth licensee as defined in the WHS Act and Regulations.
For more information about PCBUs in Comcare’s jurisdiction, refer to www.comcare.gov.au.
TRIM
(Comcare use only)
Workplace number
(If previously notified)
WHS-HCM002 September 2018
2
SECTION 1. NOTIFICATION TYPE
(This section is required to be completed for each unique type of notification)
Select one:
Notification of Schedule 11 hazardous chemical exceeding manifest quantities
(Complete Sections 1, 2, 3, 4, 5, 6, 7, 8 and 10)
Schedule 11 hazardous chemical no longer stored at manifest quantities at the site
(Complete Sections 1, 2, 3, 4 and 10)
Amendment to details (Complete Sections 1, 2, 3, 4, 6, 7, 8 and 10)
Abandonment of tank (Complete Sections 1, 2, 3, 4, 9 and 10)
SECTION 2. NOTIFIER DETAILS (PCBU)
Name (e.g. Commonwealth agency/
organisation)
ACN (if applicable) ABN
Postal address
Suburb/town State Postcode
SECTION 3. NAME AND DETAILS OF CONTACT PERSON
FOR NOTIFIER
Surname
First name
Contact person’s designation/title
Phone number Mobile number
Fax number
Email
Postal address for individual
Suburb/town State Postcode
Notification type
completed?
Y N
Notifier details
(PCBU)completed?
Y N
Name and details of
contact person for
notifier completed?
Y N
WHS-HCM002 September 2018
3
SECTION 5. PREVIOUS OCCUPIER OF THE SITE
(IF KNOWN) (Supply the details of the previous occupant or land owner)
Name of occupier
ACN (if applicable) ABN
Current postal address (if known)
Duration of occupancy (if known) from to
SECTION 6. DETAILED INFORMATION ABOUT THE
ACTIVITIES UNDERTAKEN AT THE WORKPLACE USING,
HANDLING OR STORING THE SCHEDULE 11 HAZARDOUS
CHEMICAL
What is the type of business or undertaking being conducted? (For example—research facility, fuel
storage depot)
Which are the activities of the business or undertaking that involve using, handling or storing schedule 11
hazardous chemicals? (For example—chemical research and analysis)
SECTION 4. WORKPLACE DETAILS (Where the chemicals or the tank are located)
Name of workplace
Street number and street name
Suburb/town State Postcode
Workplace details
completed?
Y N
Previous occupier
of the site (if known)
completed?
Y N
Detailed information
about the activities
undertaken at the
workplace using,
handling or storing
the Schedule 11
hazardous chemical
completed?
Y N
WHS-HCM002 September 2018
4
SECTION 7. WHAT ARE THE DETAILS OF THE SPECIFIC
SCHEDULE 11 HAZARDOUS CHEMICALS THAT ARE USED,
HANDLED OR STORED?
These figures should represent the maximum quantity of chemicals that would be expected to be stored, handled
or used at the workplace.
REFER TO THE HAZARDOUS CHEMICALS GUIDANCE MATERIAL—GHS/ADG CONVERSION
Item Type of
material
Category Manifest QTY Notified
amount
1 Flammable
gases
Category 1 5000L
2 Gases under
pressure
With acute toxicity, categories 1, 2, 3 or 4 500L
3 With skin corrosion categories 1A, 1B or 1C 500L
4 Aerosols 10 000L
5 Not specified elsewhere in this Table 10 000L
6 Flammable
liquids
Category 1 500L
7 Category 2 2500L
8 Category 3 10 000L
9 Any combination of chemicals from Items 6
to 8 where none of the items exceeds the
quantities in columns 4 or 5 on their own
10 000L
10 Category 4 100 000L
11 Self-reactive
substances
Type A 50kg or 50L
12 Type B 500kg or 500L
13 Type C to F 2500kg or 2500L
14 Flammable
solids
Category 1 2500kg
15 Category 2 10 000kg
16 Any combination of chemicals from Items 12
to 15 where none of the items exceeds the
quantities in columns 4 or 5 on their own
10 000kg or
10 000L
17 Pyrophoric
liquids and
pyrophoric
solids
Category 1 500kg or 500L
18 Self-heating
Substances
and mixtures
Category 1 2500kg or 2500L
19 Category 2 10 000kg or
10 000L
20 Any combination of chemicals from Items 17
to 19 where none of the items exceeds the
quantities in columns 4 or 5 on their own
10 000kg or
10 000L
What are the details
of the specific
Schedule 11
hazardous chemicals
that are used,
handled or stored
completed?
Y N
WHS-HCM002 September 2018
5
Item Type of
material
Category Manifest QTY Notified
amount
21 Substances
which in
contact with
water emit
flammable
gas
Category 1 500L or 500kg
22 Category 2 2500kg or 2500L
23 Category 3 10 000kg or
10 000L
24 Any combination of chemicals from Items 21
to 23 where none of the items exceeds the
quantities in columns 4 or 5 on their own
10 000kg or
10 000L
25 Oxidising
liquids and
oxidising
solids
Category 1 500kg or 500L
26 Category 2 2500kg or 2500L
27 Category 3 10 000kg or
10 000L
28 Any combination of chemicals from Items 25
to 27 where none of the items exceeds the
quantities in columns 4 or 5 on their own
10 000kg or
10 000L
29 Organic
peroxides
Type A 50kg or 50L
30 Type B 500kg or 500L
31 Type C to F 2500kg or 2500L
32 Any combination of chemicals from Items
30 and 31 where none of the items exceeds
the quantities in columns 4 or 5 on their
own
2 500kg or
2 500L
33 Acute
toxicity
Category 1 500kg or 500L
34 Category 2 2500kg or 2500L
35 Category 3 10 000kg or
10 000L
36 Any combination of chemicals from Items 33
to 35 where none of the items exceeds the
quantities in columns 4 or 5 on their own
10 000kg or
10 000L
37 Skin
corrosion
Category 1A 500kg or 500L
38 Category 1B 2500kg or 2500L
39 Category 1C 10 000kg or
10 000L
40 Corrosive
to metals
Category 1 10 000kg or
10 000L
41 Any combination of chemicals from Items
37 to 40 where none of the items exceeds
the quantities in columns 4 or 5 on their own
10 000kg or
10 000L
42 Unstable
explosives
50kg or 50L
What are the details
of the specific
Schedule 11
hazardous chemicals
that are used,
handled or stored
completed?
Y N
WHS-HCM002 September 2018
6
SECTION 8. PLEASE ATTACH A COPY OF THE MANIFEST
FOR SCHEDULE 11 SUBSTANCES THAT CONFORMS
TO THE REQUIREMENTS OF SCHEDULE 12 OF THE
WHS REGULATIONS.
I have attached a copy of the manifest YES
Please confirm if the workplace has an emergency plan that meets the requirements of regulation 361
YES
Please confirm if the workplace displays placards that meet the requirements of Schedule 13 of the Work
Health and Safety Regulations 2011 (Cth)
YES
IF YOU DO NOT INDICATE THAT YOU MEET THESE OBLIGATIONS YOUR NOTIFICATION WILL NOT BE
PROCESSED.
Please note: An example manifest can be found in the ‘Guidance Material for Schedule 11 hazardous
chemicals and abandonment of tanks notification’ document.
SECTION 9. DETAILED INFORMATION ABOUT THE
NOTIFICATION OF ABANDONED TANK (Details of the tank)
Tank identification or code number
Type
Capacity
Date tank was abandoned
Class of Schedule 11 hazardous chemical that the tank contained
You must attach a certificate supplied by a competent person that states that the abandonment was undertaken
in accordance with AS/NZ 1596: 2008 The Storage and Handling of LP Gas or with AS 4976: 2008 The
Removal and Disposal of Underground Petroleum Storage Tanks. Refer to the Notification of dangerous goods
on premises guide for more information.
YES (please tick) I have attached a certificate of tank abandonment from a competent person.
Please attach a
copy of the manifest
for Schedule 11
substances that
conforms to the
requirements of
Schedule 12 of the
WHS Regulations
completed?
Y N
Detailed information
about the notification
of abandoned tank
completed?
Y N
WHS-HCM002 September 2018
7
SECTION 10. DECLARATION BY NOTIFIER
(Signed by the person in Section 3)
Note: Note that in relation to section 268 of the Work Health and Safety Act 2011, Part 7.4 of the Criminal
Code Act 1995 makes it an offence for you to give Comcare false or misleading information in respect of
this notification. Should you provide false or misleading information in this notification, you will be liable
for prosecution under the Criminal Code Act 1995, and if convicted, face a penalty of up to 12 months
imprisonment.
I declare that:
> I am empowered by valid and express power, delegation in writing or authorisation in writing, to act as, for
or on behalf of the PCBU that is required to make this notification.
> The information in this notification is true and correct to the best of my knowledge.
> I consent to Comcare making enquiries and exchanging information with other Commonwealth entities
and other work health and safety regulators in the states and territories regarding any matter relevant to
this notification.
Print name Date
/ /
Signature Contact phone no.
Position title
Please fax completed forms to 1300 196 971 or post to:
Authorisations Team
Comcare
GPO Box 9905
Canberra ACT 2601
If you have any further questions on lodging or completing the form, please contact the Authorisations Team on
1300 366 979 or email WHS.Chemicals@comcare.gov.au
Declaration by notifier
completed?
Y N
GPO BOX 9905 CANBERRA 2601 | 1300 366 979 | COMCARE.GOV.AU
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FORM WHSHCM002: NOTIFICATION FORMMANIFEST QUANTITIES SCHEDULE 11 CHEMICALSABANDONED (General Public Services)

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Completed 3 July 2022

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