Download Form For Return under Water Cess Act, 1977

FORM I ( See rule4) Return regarding Water consumed during the month of......................... Name and Purpose for Address which water of the consumed Consumer I2 1. Industrial cooling .. . spraymg m mme pits or boilers feed 2. Domestic purpose 3. Processing whereby water gets polluted and the pollutants are easily bio­degfadable 4. Processing whereby water gets polluted and the pollutants are not easily bio­degradable and are toxic. Reading at Reading Quantity If the meter Quantity of Remarks the at the of water was out of water (*) beginning of end of consumed order the qualifying the first day the last in Kilo monthly for rebate of the day of litres average according calendar calendar consumption to the month under month of water for asse~e under report the previous report 3 months of working 3 j 7 4 5 period6 II (i) from Municipal water supply mains (ii) from welVtubewell (iii) from canal (iv) from river (v) from any other source (i) from Municipal water supply mains (ii) from welVtubewell (iii) from canal (iv) from river (v) from any other source (i) from Municipal water supply mains' , from welVtubewell (ii) (iii) from canal (iv) from river (v) from any other source (i) from Municipal water supply mains (ii) from welVtubewell (Hi) from canal (iv) from river (v) from any other source (*) for claiming rebate under Col.. 7 the assessee shall indicate in this column the analytical and other reports annexed to this return in support of this claim Signature of the consumer Name Address ANNEXURE TO FORM I Reportof Analysisto treated effluent showing perfonnance of the treatment plant -For themonthof """""" ... ... ... Sample collected on """""""""""'" Sampletestedon... ...... ........... Bythelaboratories...... ~...no....... S.No. Polluting Maximum Concentration Dates on which parameters as pennissible of range of There was On whichmentioned m the limits or parameters as break down underconditions imposed ranges per report or failure of perfonnanceunder consent allowed as was noticed under the plant granted per consent section 25/26 of the conditions Water (Prevention "­and Control of Pollution)Act,1974 I2 3456 Signature .. Date. ............................... Name '. Address ..