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D.1 (a) Source of water of supply (State the name of river orLake or any other source)
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| (b) State the quantity of water consumed (in lts./day) |
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| Break up of quantity of water used. |
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| (i) For process (Lts./day) |
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| (ii) For washing (Lts./day) |
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| (iii) For cooling (Lts./day) |
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| (iv) For spraying in minepits (Lts./day) |
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| (v) As boiler feed (Lts./day) |
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| (vi) For Domestic purpose (Lts./day) |
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| (vii) For Agricultural purposes (Lts./day) |
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| (viii) Other uses (specify) (Lts./day) |
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| D.2 Waste water Discharge (in m3/day) |
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| (a) Waste water discharge from |
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| (i) Process |
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| (ii) Washing |
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| (iii) Cooling |
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(iv) Sanitary/sewage from toilets/sullage from hand washingetc.
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| (v) Any other source |
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(b) (i) Amount of water lost in evaporation (in terms of %ageof total water usage)
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(ii) Amount of water lost in the product (in terms of %age oftotal water usage)
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| (iii) Total of (i) and (ii) above |
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D.3 (a) Do you propose to re-circulate any or all of theabove streams, if yes, give details of the same.
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| (b) Quantity of water in re-circulation (m3/day) |
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D.4 Details of treatment provided to waste water beforedischarge.
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| (i) Treatment of effluent generated from the process |
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| (ii) Treatment of effluent generated from washing. |
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(iii) Treatment of effluent generated from water scrubbersetc.
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| (iv) Treatment of domestic effluent. |
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| D.5 Point of final disposal of waste water Mode of disposal |
Quantity (in m3/day)
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(i) Onto land for irrigation/plantation and area of landavailable
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| (ii) Public sewer |
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| (iii) Inland surface waters |
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| (iv) River (give name) |
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| (v) Choe (give name) |
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| (vi) Drain (give name) |
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| (vii) Nallah (give name) |
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| (viii) Any other - (specify) |
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D.6(a) Are the effluents from the industry or any processtoxic ?
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| (b) If yes, |
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| (i) Volume of this effluent |
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| (ii) Proposed treatment |
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| (c) State if the industrial effluent is |
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| (i) Having unpleasant smell |
Yes/No |
| (ii) Irritating |
Yes/No |
| (iii) Corrosive |
Yes/No |
| (iv) With colours |
Yes/No |
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(d) Is there any sudden change of temperature of effluentexceeding 100 °C at any time ?
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Yes/No |
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(e) Is there any change of run away reaction in their process?, Yes/No
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(f) What is the maximum storage of hazardous chemicals inyour industry ?
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(g) Brief description of hazard management measures (attachcopies of in-plant emergency plan).
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Section E : Location of Industrial Premises of DischargePoint and Proposed Sampling Point :
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E.1 Draw in the space provided, or on separate sheet, asketch plan, as nearly as possible to scale showing the locationof the industrial premises or of the building in which they aresituated (i) premises are part of a larger building on the plan--------------------
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(a) Show the relationship of the premises of building to thenearest major road intersection and name the roads or show therelationship of the premises or building to readily identifiablelandmark;
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(b) Show any public drain, public sewer, or inland watersadjacent to the premises or building; and
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| (c) Mark the location of every discharge point. |
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E.2 State whether storm water drains are kept separate fromindustrial/domestic effluent drains
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Yes/No |
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E.3 Draw in the space provided, or on a separate sheet asecond sketch plan, as nearly as possible to scale showing thelay out of the industrial premises on the plan.
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| (a) Show the location of any one site treatment plant; |
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| (b) Mark the location of every proposed sampling point. |
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| Section F : Declaration |
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1. I/We hereby certify that the particulars given above arecorrect to the best of my/our knowledge and belief.
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| Occupier |
Manager of Industrial enterprise. |
| Signature/s--------------------------------- |
------------------------------------------ |
| Name/s------------------------------------- |
------------------------------------------ |
| (Block Letters) |
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| Date------------------------------------ |
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