| For Office Use Only |
| 1. Code No.| |- |
2. Whether the unit is situated in a critically polluted area as identified by Ministry of Environment & Forests| |- |
To be filled in by Applicant |
| Part A-General |
| 3 (a) Name of Owner/Occupier| |- |
(b) Name and address of the unit and location| |- |
4 (a) Whether the unit is generating hazardous waste as defined in the Hazardous Wastes (Management and Handling) Rules, 1989| |- |
(b) If so the category No.| |- |
5 (a) Total capital invested on the project| |- |
(b) Year of commencement of production| |- |
(c) Whether the industry works general/2 shifts/round the clock| |- |
6 (a) List and quantum of products and bye-products| |- |
(b) List and quantum of raw materials used| |- |
7. Furnish a flow diagram of manufacturing process showing input and output in terms of products and waste generated including for captive power generation and dematerialized water| |- |
PART B-Pertaining to sewage and trade effluent |
| 8. Quantity and source of water for:| |- |
(a) Cooling m3/d| |- |
(b) Process m3/d| |- |
(c) Domestic use m3/d| |- |
(d) Others m3/d| |- |
9. Sewage and trade effluent discharge| |- |
(a) quantum of discharge m3/d| |- |
(b) Is there any effluent treatment plant| |- |
(c) If yes, a brief description of unit operations with capacity| |- |
(d) Characteristics of final effluent pH| |- |
Suspended solids| |- |
Dissolved solids| |- |
Chemical Oxygen Demand (COD)| |- |
Biochemical Oxygen Demand (BOD)/20°C| |- |
Oil and grease| |- |
(Additional parameters as specified by the concerned Pollution Control Board)| |- |
(e) Mode of disposal and final discharge point (enclose .map showing discharge point)| |- |
(f) Parameters and Frequency of self-monitoring| |- |
PART C-Pertaining to stack and vent emissions |
| 10 (a) Number of stacks and vents with height and dia (m)| |- |
(b) Quality and quantity of stack emission from each of the above stacks-particulate matter t and Sulphur Dioxide(S02) (Additional parameters as specified by the concerned Pollution Control Board)| |-
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(c) A brief account of the air pollution control unit to deal with the emission| |- |
(d) Parameters and Frequency of self monitoring| |- |
PART D-Pertaining to hazardous waste and hazardous chemicals. |
| 11 Solid wastes:| |- |
(a) Total quantum of generation| |- |
(b) Quantum of hazardous waste generated and its nature, as defined under the Environment (Protection) Act, 1986. (See the Hazardous Wastes Management and Handling Rules, 1989).| |- |
(c) Mode of storage within the plant, method of disposal and any other information sought by the concerned Pollution Control Board| |- |
12 (a) Hazardous Chemicals as defined under Environment (Protection) Act, 1986(See the Manufacture, Storage and Import of Hazardous Chemicals Rules, 1989)| |- |
(b) Whether any isolated storage is involved if yes, attach details| Yes/No |
| (c) Whether emergency plans are prepared for taking| |
| -on-site measures| Yes/No |
| -off-site measures| Yes/No |