WQL 53 notification of a contaminated land investigation

Fill in this form to submit notification of a contaminated land investigation

Name *:

Email Address:

Organisation:

Address*:

Phone*:

Date:

Monday, 22 March 2010

Site Name:

Site Address*:

Legal Description / Valuation Number*:

Land Owner Name:

Land Owner, Address & Phone:

LLUR Site Number:(if known)

Type of Investigation*:

Date of Investigation:

Consents applied for: e.g. bore permits, excavation:
(please detail)

Investigation report will be supplied to ECan by*:
(date of investigation plus 2 months)