CWCO

To operate a facility producing Schedule 1 chemicals:

Protective Purpose Facility

- Permit Application / Renewal Form
- Notification Form

Chemical Weapons (Prohibition) Act 1994 - sections 17(1), 20(1), 29(1)

PLEASE READ THE GUIDE TO THIS FORM BEFORE COMPLETING IT

Indicate whether this is an Application or a Notification for calendar year:

Section A. Organisation/Institution operating facility

(ASNO reference: Site code: )

1. Facility name
2. Name of the operator of the facility and principal place of business
3. Postal address of facility
4. Street address of facility
5. Site location co-ordinates	Latitude: deg/min/sec	°/ ’/ ”/ S	Longitude: deg/min/sec	°/ ’/ ”/ E
6. Building or Structure number, if any
7. Contact
8. Title
9. Contact Details	tel:		fax:
10. Principal Researcher
11. Contact Details	tel:		fax:

If the form is being completed as a notification, and not a permit application, go to question 19

12. In the initial application enclose, as Attachment A, a detailed technical description of the facility, including facility diagrams, an inventory of equipment and a description of other Schedule 1 chemicals used and/or stored at the facility.

Section B Details of anticipated activities at the Protective Purpose Facility with Schedule 1 chemicals for the calendar year for which the permit is sought

USE ONE COPY OF THIS PAGE FOR EACH SCHEDULE 1 CHEMICAL TO BE PRODUCED

13. IUPAC chemical name or, if unknown, Schedule 1 family name
14. Structural formula
15. CAS registry number (if assigned)
16. Quantity anticipated to be produced
17. Anticipated periods of production (indicate months when activity is expected)
18. Brief description of the purpose of anticipated production

Section C. Confidentiality

19. If there is any information in this form which you believe requires particular protection, describe that information against the appropriate classification:

classification
OPCW - Restricted
OPCW - Protected
OPCW - Highly Protected

Note: The Chemical Weapons (Prohibition) Act prescribes penalties for the provision of false or misleading information.

Signed by/on behalf of the applicant or notifier

.......................................................….... …............………..................................................

(Signature) (Full Name)

Dated ......................................., 20........

To operate a facility producing Schedule 1 chemicals: Research Facility

- Permit Application / Renewal Form

- Notification Form

Chemical Weapons (Prohibition) Act 1994 - sections 17(1), 20(1), 29(1)

PLEASE READ THE GUIDE TO THIS FORM BEFORE COMPLETING IT

Indicate whether this is an Application or a Notification for calendar year:

Section A. Organisation/Institution operating facility

(ASNO reference: Site code: )

1. Facility name
2. Name of the operator of the facility and principal place of business
3. Postal address of facility
4. Street address of facility
5. Site location co-ordinates	Latitude: deg/min/sec	°/ ’/ ”/ S	Longitude: deg/min/sec	°/ ’/ ”/ E
6. Building or Structure number, if any
7. Contact
8. Title
9. Contact Details	tel:		fax:
10. Principal Researcher
11. Contact Details	tel:		fax:

If the form is being completed as a notification, and not a permit application, go to question 19

Section B Details of anticipated activities at the Research Facility with Schedule 1 chemicals for the calendar year for which the permit is sought

USE ONE COPY OF THIS PAGE FOR EACH SCHEDULE 1 CHEMICAL TO BE PRODUCED

13. IUPAC chemical name or, if unknown, Schedule 1 family name
14. Structural formula
15. CAS registry number (if assigned)
16. Quantity anticipated to be produced
17. Anticipated periods of production (indicate months when activity is expected)
18. Brief description of the purpose of anticipated production

Section C. Confidentiality

19. If there is any information in this form which you believe requires particular protection, describe that information against the appropriate classification:

classification
OPCW - Restricted
OPCW - Protected
OPCW - Highly Protected

Note: The Chemical Weapons (Prohibition) Act prescribes penalties for the provision of false or misleading information.

Signed by/on behalf of the applicant or notifier

.......................................................….... …............………..................................................

(Signature) (Full Name)

Dated ......................................., 20.......

To operate a facility acquiring, retaining, using and/or transferring Schedule 1 chemicals: Consumption Facility

- Permit Application / Renewal Form
- Notification Form

Chemical Weapons (Prohibition) Act 1994 - sections 17(1), 20(1), 29(1)

PLEASE READ THE GUIDE TO THIS FORM BEFORE COMPLETING IT

Indicate whether this is an Application or a Notification for calendar year:

Section A. Organisation/Institution operating facility

(ASNO reference: Site code: )

1. Facility name
2. Name of the operator of the facility and principal place of business
3. Postal address of facility operator
4. Street address of facility
5. Facility location co-ordinates	Latitude: deg/min/sec	°/ ’/ ”/ S	Longitude: deg/min/sec	°/ ’/ ”/ E
6. Facility building or structure number, if any
7. Contact
8. Title
9. Contact Details	tel:		fax:
10. Principal Researcher
11. Contact Details	tel:		fax:

If the form is being completed as a notification, and not a permit application, go to question 23

Section B Details of anticipated activities at the Consumption Facility with Schedule 1 chemicals for the calendar year for which the permit is sought

USE ONE COPY OF THIS PAGE FOR EACH SCHEDULE 1 CHEMICAL TO BE ACQUIRED, RETAINED, USED AND/OR TRANSFERRED

13. IUPAC chemical name or, if unknown, Schedule 1 family name
14. Structural formula
15. CAS registry number (if assigned)
16. Quantity likely to be acquired
17. Details of supplier
18. Maximum quantity likely to be retained
19. Quantity likely to be used
20. Nature of Use	Please describe (in words):
21. Quantity likely to be transferred from the facility
22. Details of recipient of any likely transfer

Section C. Confidentiality

23. If there is any information in this form which you believe requires particular protection, describe that information against the appropriate classification:

classification
OPCW - Restricted
OPCW - Protected
OPCW - Highly Protected

Note: The Chemical Weapons (Prohibition) Act prescribes penalties for the provision of false or misleading information.

Signed by/on behalf of the applicant or notifier

.......................................................….... …............………..................................................

(Signature) (Full Name)

Dated ......................................., 20.......

Production, processing or consumption of Schedule 2 chemicals

- Permit Application / Renewal Form

- Notification Form

Chemical Weapons (Prohibition) Act 1994 - sections 17(1), 20(1), 29(1)

PLEASE READ THE GUIDE TO THIS FORM BEFORE COMPLETING IT

Application / Notification for calendar year:

Section A. Company or organisation operating facility (ASNO reference: )

	current information (this column for ASNO use only)		correct or update if necessary
1. Name and principal place of business
2. Postal address
3. Contact
4. Title
5.	tel:	fax:	tel:	fax:

Section B. Facility (plant site) (ASNO site code : )

	current information		correct or update if necessary
6. Name
7. Street address (sufficient to uniquely identify the site)
8. Contact
9. Title
10.	tel:	fax:	tel:		fax:
11. Site location	Latitude:	°/ ’/ ”/ S	Latitude: deg/min/sec	°/ ’/ ”/ S
co-ordinates	Longitude:	°/ ’/ ”/ E	Longitude: deg/min/sec	°/ ’/ ”/ E
12. Number of relevant plants at the site

Section C. Details of a declarable plant producing, processing or consuming Schedule 2 chemicals

COPY THIS PAGE IF MORE THAN ONE SCHEDULE 2 PLANT IS TO BE DECLARED AT THE SITE

Plant Site code [†] : Plant code†:

	current information	correct or update if necessary
13. Plant name
14. Location within site : (include any building or structure number)
15. Schedule 2 chemicals are / were :		produced processed consumed
16. Other activities at the plant	with the Schedule 2 chemical:	with the Schedule 2 chemical:  production processing  storage  consumption research / development  re-packaging, distribution other :
	otherwise:	otherwise:  production  processing  storage  consumption  research /development  re-packaging, distribution other :
17. Main products
18. Plant function		 dedicated  multi-purpose

19. If one or more schedule 2 chemicals are/were produced, processed or consumed at the plant, estimate the annual production capacity for each chemical [*]:

CAS number of chemical	production capacity (tonnes)	calculation method
		 nameplate*  design*
		 nameplate  design

Section D. Details of anticipated activities at each plant with Schedule 2 chemicals for
the calendar year for which the permit is sought

USE ONE COPY OF THIS PAGE FOR EACH SCHEDULE 2 CHEMICAL THAT IS TO BE PRODUCED, PROCESSED OR CONSUMED AT EACH PLANT

20. Plant name :

ASNO code:

21. Details of Schedule 2 chemical:

chemical name	CAS number	concentration by weight in product
		%
trade name of the chemical or product :

22. Estimate the quantity of the Schedule 2 chemical product to be produced, processed, or consumed at the plant. Include also an estimate of the variation that is reasonably possible. If possible, indicate the anticipated time period(s) in which the activity will take place (eg. June- July) :

	Quantity	+/-	anticipated time period(s) for activity
production :	kg	%
processing :	kg	%
consumption :	kg	%

If the form is being completed as a notification, and not a permit application, go to question 27 :

23. If the Schedule 2 chemical is to be processed or consumed at the plant, specify the product type:

24. If the Schedule 2 chemical (or a product containing it) is to be exported from the site, specify the importing countries, and indicate the typical concentration of the chemical in the product :

countries:

concentration : %

25. If the Schedule 2 chemical (or a product containing it) is to be sold or transferred within Australia, specify the type of recipient, indicate the typical concentration of the Schedule 2 chemical in the product, and (if known) indicate the final product types :

other industry trader other :	concentration : %
final product types:

26. Specify any other purpose for which the Schedule 2 chemical will be produced, processed or consumed:

Section E. Confidentiality

27. If there is any information in this form which you believe requires particular protection (eg. because unauthorised disclosure could harm your business interests), describe that information against the appropriate classification:

classification	current information	correct or update if necessary
OPCW - Restricted
OPCW - Protected
OPCW - Highly Protected

Note: The Chemical Weapons (Prohibition) Act prescribes penalties for the provision of false or misleading information.

Signed by/on behalf of the applicant or notifier

.......................................................….... …............………..................................................

(Signature) (Full Name)

Dated ......................................., 20........

Production of Schedule 3 chemicals

- Permit Application / Renewal Form

- Notification Form

Chemical Weapons (Prohibition) Act 1994 - sections 17(1), 20(1), 29(1)

PLEASE READ THE GUIDE TO THIS FORM BEFORE COMPLETING IT

Application / Notification for calendar year:

Section A. Company or organisation operating facility (ASNO reference: )

	current information (this column for ASNO use only)		correct or update if necessary
1. Name and principal place of business
2. Postal address
3. Contact
4. Title
5.	tel:	fax:	tel:	fax:

Section B. Facility (plant site) (ASNO site code : )

	current information		correct or update if necessary
6. Name
7. Street address (to uniquely identify the site)
8. Contact
9. Title
10.	tel:	fax:	tel:		fax:
11. Site location	Latitude:	°/ ’/ ”/ S	Latitude: deg/min/sec	°/ ’/ ”/ S
co-ordinates	Longitude:	°/ ’/ ”/ E	Longitude: deg/min/sec	°/ ’/ ”/ E
12. Number of relevant plants at site
13. Other chemicals produced at site

COPY THIS PAGE IF THE AVAILABLE SPACE IS NOT SUFFICIENT

Section C. Details of each declarable plant producing Schedule 3 chemicals

Plant Site code : Plant code: (issued by ASNO)

	current information	correct or update if necessary
14. Plant name
15. Building / Structure Number		Bldg: Structure:
16. Main activities at the plant		 Production  Processing  R&D  Consumption  Storage  Re-packaging, distribution Other :

Section D. Details of each Schedule 3 chemical to be produced

17. Chemical Name :
trade name :				CAS No. :
	18. Quantity Produced	+/-	19. Purpose of Production
anticip-ated for Permit Year	tonnes	%	 Sale or transfer to other industry  In-line consumption as produced  Synthetic intermediate stored and/or used on site Other :

Section E. 20. Describe any information in this form which you believe requires protection
(eg. as unauthorised disclosure could harm your business interests), against the appropriate classification:

Classification	current information	correct or update if necessary
OPCW - Restricted
OPCW - Protected
OPCW - Highly Protected

Note: The Chemical Weapons (Prohibition) Act prescribes penalties for the provision of false or misleading information.

Signed by/on behalf of the facility operator:

.......................................................….... …............………..................................................

(Signature) (Full Name)

Dated ......................................., 20........

FORM 4

Notification of a facility producing Unscheduled Discrete Organic Chemicals

Chemical Weapons (Prohibition) Act 1994 - section 29(1)

PLEASE READ THE GUIDE TO THIS FORM BEFORE COMPLETING IT

Notification of activities during calendar year:

Section A. Company or organisation operating facility (ASNO reference: )

	current information (this column for ASNO use only)		correct or update if necessary
1. Name and principal place of business
2. Postal address
3. Contact
4. Title
5.	tel:	fax:	tel:	fax:

Section B. Facility (plant site) : (ASNO site code : )

	current information			correct or update if necessary
6. Name
7. Street address (to uniquely identify the site)
8. Contact
9. Title
10.	tel:		fax:	tel:		fax:
11. Site location co-ordinates	Latitude:	°/ ’/ ”/ S		Latitude: deg/min/sec	°/ ’/ ”/ S
	Longitude:	°/ ’/ ”/ E		Longitude: deg/min/sec	°/ ’/ ”/ E
12. Number of relevant plants at site
13. Other chemicals produced at site
14. Other activities at the plant site				 production  processing  storage  consumption  research/ development  re-packaging, distribution other :

(ASNO site code: )

COPY THIS PAGE, OR USE AN ATTACHMENT, IF THE AVAILABLE SPACE IS NOT SUFFICIENT

Section C. 15. List unscheduled discrete organic chemicals (DOCs) produced at the site, with production figures for the calendar year in respect of which notification is made. For a site producing many DOCs, chemically similar compounds may be grouped together - but do not group PSF with non-PSF chemicals. In the right-most column indicate DOCs or groups that are PSF chemicals.

chemical name / group description	CAS number	production (tonnes) 100% by weight	PSF (y/n)

Section D. 16. Name, and estimate total production of PSF chemicals, for each plant at the site where more than 30 tonnes of any individual PSF chemical were produced during the year notified. In the right column, indicate whether production of any individual PSF chemical at the plant exceeded 200 tonnes.

Plant name	Plant code	PSF production (tonnes) 100% by weight	>200(y/n)

Section E. 17. If there is any information in this form which you believe requires protection
(eg. as unauthorised disclosure could harm your business interests), describe that information against the appropriate classification :

Classification	current information	correct or update if necessary
OPCW - Restricted
OPCW - Protected
OPCW - Highly Protected

Note: The Chemical Weapons (Prohibition) Act prescribes penalties for the provision of false or misleading information.

Signed by/on behalf of the facility operator:

.......................................................….... …............………................................................………

(Signature) (Full Name)

Dated ......................................., 20........

Application for transfer of a permit

Chemical Weapons (Prohibition) Act 1994 - section 24(1)

PLEASE READ THE GUIDE TO THIS FORM BEFORE COMPLETING IT

Section A. Details of applicant (transferee)

1. Name and principal place of business
2. Postal address
3. Contact
4. Title
5.	tel:	fax:

Section B. Identification of Facility (plant site)

6. ASNO site code :
7. Site Name
8. Street address
9. Description of plants and processes transferred

Section C. New Site contact details

10. Contact
11. Title
12.	tel:	fax:

Note: The Chemical Weapons (Prohibition) Act prescribes penalties for the provision of false or misleading information.

Signed by/on behalf of the applicant

.......................................................….... …............………..................................................

(Signature) (Full Name)

Dated ......................................., 20…..

Production, acquisition, use or transfer of Schedule 1 chemicals

- Report of anticipated activities

Chemical Weapons (Prohibition) Act 1994 (Amended) - section 30

Report in respect of calendar year:

Section A. Organisation/Institution operating facility (ASNO reference: )

	current information (this column for ASNO use only)		correct or update if necessary
1. Facility name
2. Name and postal address of the operator of the facility
3. Contact
4. Title
5.	tel:	fax:	tel:	fax:
6. Facility location
7. Site Contact
8. Title
9.	tel:	fax:	tel:	fax:

10. After completing Section B, describe any information in this form which you believe requires protection (eg. as unauthorised disclosure could harm your business interests) against the appropriate classification:

Classification	current information	correct or update if necessary
OPCW - Restricted
OPCW - Protected
OPCW - Highly Protected

Note: The Chemical Weapons (Prohibition) Act prescribes penalties for the provision of false or misleading information.

Signed by/on behalf of the facility operator:

.......................................................….... …............………..................................................

(Signature) (Full Name)

Dated ......................................., 20..….

Production, acquisition, use, storage or transfer of

Schedule 1 chemicals

- Report of past activities

Chemical Weapons (Prohibition) Act 1994 (Amended) - section 30

Report in respect of calendar year:

Section A. Organisation/Institution operating facility (ASNO reference: )

	current information (this column for ASNO use only)		correct or update if necessary
1. Facility name
2. Postal address
3. Contact
4. Title
5.	tel:	fax:	tel:	fax:
6. Facility location / address :

7. After completing Section B, describe any information in this form which you believe requires protection (eg. as unauthorised disclosure could harm your business interests) against the appropriate classification:

Classification	current information	correct or update if necessary
OPCW - Restricted
OPCW - Protected
OPCW - Highly Protected

Note: The Chemical Weapons (Prohibition) Act prescribes penalties for the provision of false or misleading information.

Signed by/on behalf of the facility operator:

.......................................................….... …............………..................................................

(Signature) (Full Name)

Dated ......................................., 20……

Production, processing or consumption of
Schedule 2 chemicals

- Report of anticipated activities

Chemical Weapons (Prohibition) Act 1994 (Amended) - section 30

Report in respect of calendar year:

Section A. Company or organisation operating facility (ASNO reference: )

	current information (this column for ASNO use only)		correct or update if necessary
1. Company name
2. Postal address
3. Contact
4. Title
5.	tel:	fax:	tel:	fax:
6. Facility location / address :
7. Site Contact
8. Title
9.	tel:	fax:	tel:	fax:

10. After you have completed Section B, indicate if there is any information in this form which you believe requires particular protection (eg. because unauthorised disclosure could harm your business interests), and describe that information against the appropriate classification:

Classification	current information	correct or update if necessary
OPCW - Restricted
OPCW - Protected
OPCW - Highly Protected

Note: The Chemical Weapons (Prohibition) Act prescribes penalties for the provision of false or misleading information.

Signed by/on behalf of the facility operator:

.......................................................….... …............………..................................................

(Signature) (Full Name)

Dated ......................................., 20…..
Section B. Details of plant anticipated to produce, process or consume Schedule 2 chemicals

COPY THIS PAGE IF MORE THAN ONE SCHEDULE 2 PLANT IS LOCATED AT THE SITE, OR MORE THAN ONE SCHEDULE 2 CHEMICAL IS EXPECTED TO BE PRODUCED, PROCESSED OR CONSUMED

11. ASNO Plant code:
12. Anticipated activities at the plant	with the Schedule 2 chemical:  production  processing  storage  consumption  research / development  re-packaging, distribution other :
	with other chemicals:  production  processing  storage  consumption  research / development  re-packaging, distribution other :
13. Plant function	dedicated multi-purpose

14. Details of Schedule 2 chemical:	CAS number	concentration by weight in product
Name:		%
Trade name of the chemical or product :

15. Anticipated quantity of the Schedule 2 chemical product to be produced, processed, or consumed at the plant during the year:	production :	kg
	processing :	kg
	consumption :	kg

16. Anticipated time periods for production, processing, and/or consumption at the plant during the year:	production :
	processing :
	consumption :

17. If the Schedule 2 chemical will be processed or consumed at the plant, specify the product type:

18. If the Schedule 2 chemical (or a product containing it)
will be exported from the site, specify expected country destinations:

19. If the Schedule 2 chemical (or a product containing it) is expected to be sold or transferred within Australia, specify the type of recipient, indicate the typical concentration of the Schedule 2 chemical in the product, and (if known) indicate the final product types:

other industry trader other :	concentration : %
Final product types:

20. Specify any other purpose for which the Schedule 2 chemical could be produced, processed or consumed:

Production, processing or consumption of
Schedule 2 chemicals

- Report of past year activities

Chemical Weapons (Prohibition) Act 1994 (Amended) - section 30

Report in respect of calendar year:

Section A. Company or organisation operating facility (ASNO reference: )

	current information (this column for ASNO use only)		correct or update if necessary
1. Company name
2. Postal address
3. Contact
4. Title
5.	tel:	fax:	tel:	fax:
6. Facility location / address :

7. After you have completed Section B, indicate if there is any information in this form which you believe requires particular protection (eg. because unauthorised disclosure could harm your business interests), and describe that information against the appropriate classification:

Classification	current information	correct or update if necessary
OPCW - Restricted
OPCW - Protected
OPCW - Highly Protected

Note: The Chemical Weapons (Prohibition) Act prescribes penalties for the provision of false or misleading information.

Signed by/on behalf of the facility operator:

.......................................................….... …............………..................................................

(Signature) (Full Name)

Dated ......................................., 20……

Section B. Details of plant producing, processing or consuming Schedule 2 chemicals

COPY THIS PAGE IF MORE THAN ONE SCHEDULE 2 PLANT IS LOCATED AT THE SITE, OR MORE THAN ONE SCHEDULE 2 CHEMICAL IS PRODUCED, PROCESSED OR CONSUMED

8. ASNO Plant code:
9. Activities at the plant	with the Schedule 2 chemical: _ production processing storage _ consumption research / development _ re-packaging, distribution other :
	with other chemicals: _ production processing storage consumption research / development _ re-packaging, distribution other :
10. Plant function	dedicated multi-purpose

11. Details of Schedule 2 chemical:	CAS number	concentration by weight in product
Name:		%
trade name of the chemical or product :

12. Quantity of the Schedule 2 chemical product produced, processed, or consumed at the plant during the year:	production :	kg
	processing :	kg
	consumption :	kg

13. If the Schedule 2 chemical was processed or consumed at the plant, specify the product type:

14. If the Schedule 2 chemical (or a	Imp/Exp	Quantity	country	concentration
product containing it) was imported to, or exported from the site, list	I / E	kg		%
quantities by country, and indicate concentration in the product :	I / E	kg		%

15. If the Schedule 2 chemical (or a product containing it) was sold or transferred within Australia, specify the type of recipient, indicate the typical concentration of the Schedule 2 chemical in the product, and (if known) indicate the final product types:

other industry trader other :	concentration : %
final product types:

16. Specify any other purpose for which the Schedule 2 chemical was produced, processed or consumed:

Production of Schedule 3 chemicals

- Report of anticipated activities

Chemical Weapons (Prohibition) Act 1994 (Amended) - section 30

Report in respect of calendar year:

Section A. Company or organisation operating facility (ASNO reference: )

	current information (this column for ASNO use only)		correct or update if necessary
1. Company name
2. Postal address
3. Contact
4. Title
5.	tel:	fax:	tel:	fax:
6. Facility location / address
7. Site Contact
8. Title
9.	tel:	fax:	tel:	fax:

Classification	current information	correct or update if necessary
OPCW - Restricted
OPCW - Protected
OPCW - Highly Protected

Note: The Chemical Weapons (Prohibition) Act prescribes penalties for the provision of false or misleading information.

Signed by/on behalf of the facility operator:

.......................................................….... …............………..................................................

(Signature) (Full Name)

Dated ......................................., 20…...

Section B. Details of each declarable plant producing Schedule 3 chemicals

COPY THIS PAGE IF MORE THAN ONE SCHEDULE 3 PLANT IS LOCATED AT THE SITE, OR MORE THAN ONE SCHEDULE 3 CHEMICAL IS PRODUCED

11. ASNO Plant code:

12. Activities at the plant

 production  processing  storage  consumption

 research / development  re-packaging, distribution

other :

13. Details of Schedule 3 chemical produced during the year:		CAS number
Chemical Name :
Trade name of the chemical or product :
14. Quantity produced :	tonnes
15. Purpose of production :	 Sale or transfer to other industry  In-line consumption as produced  Synthetic intermediate stored and/or used on site Other :

________________________________________________________________________________________

NOTES:

"OPCW Restricted" information for which unauthorised disclosure would be prejudicial to the interests of Australia, or of a commercial or governmental body or citizen

"OPCW Protected" information for which unauthorised disclosure may cause substantial damage to the interests of Australia, or of a commercial or governmental body or citizen

"OPCW Highly Protected" information for which unauthorised disclosure would cause serious damage from the point of view of national security or commercial secrecy, to the interests of Australia or of a commercial or governmental body or citizen

Production of Schedule 3 chemicals

- Report of past year activities

Chemical Weapons (Prohibition) Act 1994 (Amended) - section 30

Report in respect of calendar year:

Section A. Company or organisation operating facility (ASNO reference: )

	current information (this column for ASNO use only)		correct or update if necessary
1. Company name
2. Postal address
3. Contact
4. Title
5.	tel:	fax:	tel:	fax:
6. Facility location / address

7. If a Schedule 3 chemical was imported to, or exported from the site, list quantities by country:

Chemical	Imp/Exp	quantity	country
	I / E	tonnes
	I / E	tonnes

8. After completing Section B, describe any information in this form which you believe requires protection (eg. as unauthorised disclosure could harm your business interests) against the appropriate classification:

Classification	current information	correct or update if necessary
OPCW - Restricted
OPCW - Protected
OPCW - Highly Protected

Note: The Chemical Weapons (Prohibition) Act prescribes penalties for the provision of false or misleading information.

Signed by/on behalf of the facility operator:

.......................................................….... …............………..................................................

(Signature) (Full Name)

Dated ......................................., 20.….

Section B. Details of each declarable plant producing Schedule 3 chemicals

COPY THIS PAGE IF MORE THAN ONE SCHEDULE 3 PLANT IS LOCATED AT THE SITE, OR MORE THAN ONE SCHEDULE 3 CHEMICAL IS PRODUCED

9. ASNO Plant code:

10. Activities at the plant

production _ processing _ storage consumption _ research / development _ re-packaging, distribution

other :

11. Details of Schedule 3 chemical produced during the year:		CAS number
Chemical Name :
Trade name of the chemical or product :
12. Quantity produced :	tonnes
13. Purpose of production :	Sale or transfer to other industry In-line consumption as produced Synthetic intermediate stored and/or used on site Other :

________________________________________________________________________________________

NOTES:

"OPCW Restricted" information for which unauthorised disclosure would be prejudicial to the interests of Australia, or of a commercial or governmental body or citizen

"OPCW Protected" information for which unauthorised disclosure may cause substantial damage to the interests of Australia, or of a commercial or governmental body or citizen

[†] Plant site and plant codes are issued by ASNO.

[*] Notes: 19. Nameplate capacity is production output for the declared plant, under conditions optimised for
maximum quantity for a production facility, as demonstrated by one or more test runs. Design
capacity is the corresponding theoretically calculated product output.

	Australian Government
Australian Safeguards and Non-Proliferation Office
		This person has been appointed as a national inspector for the purposes of the Chemical Weapons (Prohibition) Act 1994.
		Issued Day Month Year No. 000
Name of Inspector

If found, please return to: The Australian Safeguards and Non-Proliferation Office The R G Casey Building, John McEwen Crescent BARTON ACT 0221.
The authorised holder of this identity card-
1.	must present it for inspection if required by the occupier of a facility or site to exercise any inspection power under the Chemical Weapons (Prohibition) Act 1994 with that person’s consent;
2.	is personally responsible for its safe custody;
3.	must not alter, destroy or tamper with it, nor transfer it to any other person, nor use any identity card than his or her own;
4.	must report its loss immediately to the Director General, Australian Safeguards and Non-Proliferation Office; and
5.	after ceasing to be an inspector, must return the card to the Director General, Australian Safeguards and Non-Proliferation Office.

11. IUPAC chemical name or, if unknown, Schedule 1 family name
12. Structural formula
13. CAS registry number (if assigned)
14. Quantity anticipated to be produced
15. Anticipated periods of production (indicate months when activity is expected)
16. Purpose of anticipated production
17. Quantity likely to be acquired
18. Details of supplier
19. Purpose of anticipated acquisition
20. Quantity likely to be consumed
21. Maximum quantity likely to be stored
22. Quantity likely to be transferred from the facility
23. Details of recipient of any likely transfer

8. IUPAC chemical name or, if unknown, Schedule 1 family name
9. Structural formula
10. CAS registry number (if assigned)
11. Quantity produced
12. Name and quantity of any Schedule 1, 2 or 3 precursors used in production
13. Production methods employed
14. Quantity acquired (other than through production)
15. Details of supplier
16. Quantity consumed
17. Purpose of consumption
18. Maximum quantity stored during the year
19. Quantity stored as at the end of the year
20. Quantity transferred from the facility
21. Details of recipient of any transfer

Instrument of Approval of Forms

Note: The Chemical Weapons (Prohibition) Act prescribes penalties for the provision of false or misleading information.

Note: The Chemical Weapons (Prohibition) Act prescribes penalties for the provision of false or misleading information.

Note: The Chemical Weapons (Prohibition) Act prescribes penalties for the provision of false or misleading information.

Note: The Chemical Weapons (Prohibition) Act prescribes penalties for the provision of false or misleading information.

Note: The Chemical Weapons (Prohibition) Act prescribes penalties for the provision of false or misleading information.

Signed by/on behalf of the facility operator:

Note: The Chemical Weapons (Prohibition) Act prescribes penalties for the provision of false or misleading information.

Signed by/on behalf of the facility operator:

Note: The Chemical Weapons (Prohibition) Act prescribes penalties for the provision of false or misleading information.

Note: The Chemical Weapons (Prohibition) Act prescribes penalties for the provision of false or misleading information.

Signed by/on behalf of the facility operator:

Section B. Details of each Schedule 1 chemical expected to be produced, acquired, used or transferred

Note: The Chemical Weapons (Prohibition) Act prescribes penalties for the provision of false or misleading information.

Signed by/on behalf of the facility operator:

Section B. Details of each Schedule 1 chemical produced, acquired, used, stored or transferred

Note: The Chemical Weapons (Prohibition) Act prescribes penalties for the provision of false or misleading information.

Signed by/on behalf of the facility operator:

Note: The Chemical Weapons (Prohibition) Act prescribes penalties for the provision of false or misleading information.

Signed by/on behalf of the facility operator:

I / E

I / E

Note: The Chemical Weapons (Prohibition) Act prescribes penalties for the provision of false or misleading information.

Signed by/on behalf of the facility operator:

Section B. Details of each declarable plant producing Schedule 3 chemicals

I / E

I / E

Note: The Chemical Weapons (Prohibition) Act prescribes penalties for the provision of false or misleading information.

Signed by/on behalf of the facility operator:

Section B. Details of each declarable plant producing Schedule 3 chemicals

10. Name and principal place of business
11. Contact
12. Title
13.	tel:	fax: