Download Application for Consent for Emission / Continuation of Emission

- 1 - FORM I (b) (See Rule 10) Application for consent for emission / continuation of emission under section 21 or the Air (Prevention and Control of Pollution) Act, 1981 (14 of 1981). From, Date : ***, ***, ***, ***. To, The Chairman, The Goa State Pollution Control Board, Dempo Tower, Patto, Panaji, Goa - 403 001. Sir, I / We hereby apply for Consent/Renewal of Consent under section 21 or the Air (Prevention and Control of Pollution) Act, 1981 (14 of 1981) to bring in to use a new / altered *stack for the discharge of emission / to begin to make a new discharge of emission / to continue to discharge emission* from stack in industry owned by me / us _***********. The annexure, appendices, other relevant particulars and plans are attached herewith in duplicate. I / We further declare that the statements made and information furnished in the Annexures, appendices and plans are true to the best of my / our knowledge. I / We understand that it is an offence to make a false statement in applying for any proposed consent (vide section 38(f) of the said Act, 1981). - 2 - I / We hereby submit that in case of change of the point or the quantity of the emission or its quality a fresh application for CONSENT shall be submitted for such changes and until such CONSENT is granted, no changes shall be made. I / We hereby agree to submit to the Board, an application for RENEWAL OF CONSENT three months in advance of the date of expiry mentioned in the consent order. I / We undertake to furnish any other information within ONE MONTH of its being called for by the Board. I / We enclose herewith the Bank Pay Order No. ******* dated ******* for Rs. ********** (Rupees ************ only) in favor of Member Secretary, Goa State Pollution Control Board, Panaji as Fees** payable under section 21 of the Act. Yours faithfully Signature : Name of the applicant: ***. ***, ***. Address: ***. ***. ***. ***. *Strike out which is not relevant **Please see Table. - 3 - ANNEXURE TO FORM I (b) Note : Any applicant knowingly giving incorrect information or suppressing any information pertaining thereto shall be liable to be punished under the Act. While filling this Annexure, the applicant not concerned with any of the item shall state "Not concerned" against the relevant one. (1) Full Name of the applicant (in block letters) : ******. (2) Nationality of the applicant : *****. (3) Status of the Applicant : (a) Individual : (b) Proprietary : (c) Partnership firm (whether registered or unregistered) : (d) Joint family Concern : (e) Private Limited Company : (f) Public Limited Company : (g) Government Company : (1) State Government : (2) Central Government : (3) Union Territory : (h) Foreign Company. (If foreign company, details of registration, incorporation, etc.) : (i) Any other Association or Body (4) (a) Full name of industry / Factory / Institute / Premises / Area / Land / Treatment Plant / Local body with Address and Telephone No. : **. - 4 - (b) Name of the person authorised to sign this form : **. : District : Taluka : Town : Village : Revenue Survey No. : (5) Give Revenue / Survey Number of land / Premises for which the application is made stating District, Taluka and Village. Area in Hectares : (6) (a) State the month and the year in which the Industry / Factory / Institute / Premises / Area / Land / Treatment Plant was actually put to commission or proposed to be put in to commission. : (b) Gross investment in the industry and year of investment. : (c) Gross Fixed Assets value of the industry. : Municipality : Panchayat : Industrial Estate : Defense Department : Port Trust : (7) State the Civil / Military / Defense / Industrial Estate etc., under whose administrative jurisdiction the applicants land / premises is situated. Prohibited Area : (8) (a) State whether the Land / Premises / factory / industry / has been declared as prohibited : Yes / No - 5 - area (b) If Yes, state the name of the Authority and furnish a certified copy of the order under which the area has been declared as prohibited. : (9) Is the Industry / Factory for which application is made closed on any days of the week? If so, give the days on which it is closed. : Yes / No : (a) Full year. -. (10) State the working season in a year for the Industry / Factory. (b) part From - To -. No. of workers attending the factory Shift No. 1 Hours. Shift No. 2 Hours. Shift No. 3 Hours. General Shift Hours. (11) (a) (b) Number of workers residing in the premises. : (12) Indicate the present use of the land in the vicinity (5 K.m. radius) of the : (1) Human settlement of more than 1000 population. (Specify population and distance from the plants) : (2) Commercial : (3) Industrial : (4) Fisheries : (5) Sanctuary / national park / hills / mountains : (6) Ancient monuments : (7) Agriculture : (13) Climatological and Meteorological details (if available): - 6 - (a) Indicate the climate condition at site. (e.g. arid, semi-arid etc.,) : (b) Rainfall : yearly average rain : (c) Temperature: seasonal range. : (d) Information on speed and direction of wind. : (e) Humidity and solar radiation : (14) Give the list of the raw materials used (tons / day). Sr. No. Name of the material Principal use Consumption tpd A process flow diagram must be included with this statement showing entry and exit points of all raw materials, intermediate products, by products and finished products. Label process and air emission and its control equipment. (15) Fuels consumption in tons/day. Name Consumpti on tpa Calorific Value Kcal/kg Ash content % Sulphur content % Others (specify) (a) Wood (b) Coal ( c)LSHS (d) FO (e) LDO (f) HSD (g) Kerosene (h) Naphtha (i) Other (specify) (16) (a) Give the list of names of products and by-products manufactured per day: - 7 - Sr. No. Name of product Actual production Installed capacity (b) Attach process description of different products while highlighting accident prone and hazardous areas and also with (emission, waste-water and solid waste) generation areas: (enclose separately) (c) State Batch / Continuous process: (17) Furnaces / cupolas: (i) Installed. : (ii) In use. : (b) Date of installation. : (c) Capacity. : (d) Purpose used. : (18) Boilers: (a) No. of Boilers : (i) Installed. : (ii) In use. : (b) Type. : No. (c) Capacity. (Tones/hr.) : Cap. (d) Method of Fuel charging. : (i) Oil / Gas burner : (ii) Grate charges (manual / mechanical) : - 8 - (e) Quantity of fuel used in boiler (lt/hr.) : (19) D. G. Sets : (a) No. of D.G. sets : (i) Installed : (ii) In use : No. 1 2 3 4 (b) Date of installation : Date ( c) Rated capacity (KVA) : KVA (d) Name & qty of fuel used (lt/hr) : HSD (20) Give details if Air Pollution Control System with specifications and drawings for air pollutants: (a) Existing: (b) Proposed Give detailed specifications for cyclones, Electrostatic precipitators, scrubbers, Bag filters, etc. ( c) Give detail of laboratory facilities available for analysis of emission. (21) Give details of atmospheric emission for each stack (Process/Boiler/DG Sets/others (specify) in Sheet - I enclosed to the application) (22) Fuel gas emissions: Analysis of fuel gas in mg/m3. (For Boilers, D. G. Sets & other oil/gas fired equipment) - 9 - Stack No. Type of Fuel Qty of Fuel Used Kgs/hr Type of firing SO2 mg/Nm3 HC CO Particulate matter mg/Nm3 Other (specify) mg/Nm3 (23) Process emissions: (24) Give details and percentage of recycling or re-use of waste water / treated effluent / other products, if envisaged: (25) State the total qty. of Air handled by ventilation equipment. Specify size & no. of equipment's installed or to be installed. Location Size Qty. of air handled No. of equipments installed (26) Give the following details: (a) The estimated / actual expenditure for implementing the scheme to control Air pollution. : (b) Annual operation and maintenance cost of Air pollution control plant, if any. : ( c) Further action that is being taken by the firm to control Air : - 10 - Pollution. (d) Other relevant information, if any. : Signature(s): Name of the Applicant(s): ****. Address of Applicant(s): ****. ****. *****. ****. - 11 - SHEET - I Stack height in Mts. Stack top Stack No. Stack attached to Material of construction Above the roof Above the ground Round / Square / Rectangular Inside size at top Gas qty. m3/hr Flue gas Temp. oC Exit gas velocity (m/sec)