Part 1 - Waste Producer

  • Individual Document Number

  • Location (choose location via the map locator, or write the closest road and closest town)
  • Select the area of waste collection

  • Well name

  • Photo of the site the waste was collected from

  • Transport company

  • Transporter - Name and Signature

  • Date and time

  • Local Government area

  • Waste Type

  • If waste type not listed, please describe in detail:

  • Photo of waste

Origin Energy Representative - contact details

  • Position title

  • Contact number of Origin Representative

  • Origin Energy Representative - name and signature

Waste amount

  • Amount of waste - choose one slider below:

  • Unit of measure

  • Amount of waste 0-1000 litres or cubic metres

  • Amount of waste 100-50000 litres or cubic metres

Waste Receiving Facility

  • Choose the nominated Waste receiving facility

Part 2 - Waste Transporter

  • Transporting company

  • Transporter name and signature

  • Vehicle Registration Number

  • Vehicle Registration Number - 2nd trailer

  • Vehicle Registration Number - 3rd trailer

Part 3 - Waste Receiver

  • Address of Waste Receiver
  • Name of Waste Receiving Facility

  • Amount of waste received

  • Intended Disposal

  • Waste Receiver name and signature (I acknowledge the receipt of the waste described in Part 1)

  • Contact number

The templates available in our Public Library have been created by our customers and employees to help get you started using SafetyCulture's solutions. The templates are intended to be used as hypothetical examples only and should not be used as a substitute for professional advice. You should seek your own professional advice to determine if the use of a template is permissible in your workplace or jurisdiction. You should independently determine whether the template is suitable for your circumstances.