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YES NO NOT SURE<br />

IF YES, WHAT LEVEL OF ASSESSMENT?<br />

ASSESSMENT ON PROPONENT INFORMATION<br />

PUBLIC ENVIRONMENTAL REVIEW<br />

PROPONENT DECLARATION (To be completed by the proponent)<br />

I, Geoffrey Ross Ladyman declare that the information contained in this form is, to my<br />

knowledge, true and not misleading.<br />

Signature:<br />

Name (print): Geoffrey Ross Ladyman<br />

Position: Sole Director Company: Dumpna Pty Ltd<br />

Date: 10/1/2011<br />

2

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