Download Application for Consent for Operation

- 1 - FORM IV (b) (See Rule 29) Application for consent for operation of industry or process or any treatment and disposal system for discharge / continuation of discharge under section 26 or the Water (Prevention and Control of Pollution) Act, 1974 (6 of 1974). From, Date : ***** ****, ****, ***, ***. To, The Chairman, The Goa State Pollution Control Board, Dempo Towers, Patto Plaza, Panaji, Goa - 403 001. Sir, I / We hereby apply for Consent/Renewal of Consent under section 25 of the Water (Prevention and Control of Pollution) Act, 1974 (6 of 1974), for operation or process or any treatment and disposal system or any extension or addition there to, to bring into use any new or altered outlet for discharge of *sewage / trade effluents , to continue to discharge sewage / trade effluent * from land premises 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 42(1) of the Act, 1974). - 2 - I / We hereby submit that in case of change of the point or the quantity of discharge or its quality or any other modifications, 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 further understand that only the dates on which all the relevant particulars are furnished by me/us in order to make the application complete in all respects, will be reckoned as the date of making the application, irrespective of the date of submission of the original application, which is incomplete. I / We enclose herewith the Bank deposit voucher for Rs. 97000.00 (Rupees ninety seven thousand only) in favor of Member Secretary, Goa State Pollution Control Board, Panaji as Fees** payable under section 25 of the Act. Yours faithfully Signature : Name of the applicant: ******. ******, Address: ******. *******. *******. *******. *Strike out which is not relevant **Please see Table. - 3 - ANNEXURE TO FORM IV (b) Note : Any applicant knowingly giving incorrect information or suppressing any information pertaining thereto shall be liable to be punished under the Act, 1974. 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 : - 4 - body with Address and Telephone No. (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 : (7) State the Civil / Military / Defense / Industrial Estate etc., under whose administrative jurisdiction the applicants land / premises is situated. Port Trust : - 5 - Prohibited Area : (8) (a) State whether the Land / Premises / factory / industry / has been declared as prohibited 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) (a) 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. : (b) State the working season in a year for the Industry / Factory. : (a) Full year. (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. ( c) (d) Number of workers residing in the premises. : (10) Give the list of materials, (metals, alloys, chemicals, oils, fuel, etc.) used per month Raw materials Name Quantity / month Metal & alloy Chemicals : Organic - 6 - Inorganic Dyes Pesticides Others Oil & Grease. (11) Fuels: Name Quantity Kl/month (a) Wood (b) Coal ( c)LSHS (d) Furnace Oil (e) LDO (f) HSD (g) Kerosene (h) Naphtha (i) Other (specify) (12) (a) Give the list of names of products and by-products manufactured per day: Sr. No. Name of product Actual production Installed capacity - 7 - (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) Attach process flow diagram with mass balance: (d) State Batch / Continuous process: (13) State daily quantity of water used in kilo litres: Sr. No. Use Quantity in Kilo litres / day (a) For manufacturing process (b) As wash water (c ) As cooling water (d) As boiler feed (e) Domestic. (f) D. M Water. (g) Agriculture. (h) Spray in mines. (i) Other uses (Incinerator, fire services, projects etc.) (14) State daily quantity of wastewater generated in kilolitres. Sr. No. Source of waste water Quantity in Kilo litres / day (a) Manufacturing process (b) Wash water - 8 - (c ) Cooling water (d) Boiler plant. (e) D. M Water plant. (f) Domestic. (g) Other uses (specify) (15) Give material balance of the water consumption in different operations including waste-water generation. (16) State whether you have any treatment plant for industrial, domestic or combined effluents: yes / No. If yes, attach the description of the process of treatment, detailed engineering drawing along with design details. Also attach analysis report of effluents. (17) What monitoring arrangement is currently there or proposed: (18) Give the quantitative disposal of treated effluent in kld. Provided for the place mentioned below: Sr. No. Place of disposal Domestic Industrial Mixed (i) Stream / River / Nallah (ii) On land for irrigation / gardening. (iii) Inland water. - 9 - (iv) Sea / tidal water. (v) On land for percolation. (vi) PWD Sewer. (vii) Others (specify) (19) State the area of land used for 18(ii) above in hectares: (20) (a) Is the effluent toxic? : Yes / No (b) State if the induistrial effluent is (i) Having unpleasant smell : Yes / No (ii) Irritating : Yes / No (iii) Corrosive : Yes / No (iv) With colour : Yes / No, slightly coloured. ( c) Is there any sudden change of temperature of effluent exceeding 10oC at any time? : Yes / No (21) Are facilities available with the applicant for carrying out the following tests of the waste-water? Existing Proposed (i) Physical Yes / No Yes / No (ii) Chemical Yes / No Yes / No (iii) Bacteriological Yes / No Yes / No (iv) Toxicological Yes / No Yes / No (22) State details of solid waste generated in the manufacturing process and / or waste-water treatment. Sr. No. Nature of waste Qty./month Method of disposal (Incineration / landfill / city pickup / sale / others (specify) - 10 - (23) (a) Quantum of hazardous waste generated and its nature, as defined under the Environment (Protection) Act, 1986 (29 of 1986). (See Hazardous Wastes Management and Handling Rules, 1989) : (b) Mode of storage within the plant, method of disposal, any other information sought by GSPCB. : (24) (a) Hazardous chemicals as defined under the Environment (Protection) Act, 1986 (29 of 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. (25) Give details and percentage of re-cycling or re-use of waste-water / treated effluent / other products, if envisaged : (26) (For local bodies only) (a) Present population. : - 11 - (b) Population covered under regular sewerage facilities. : ( c) Population covered under conservancy latrines. : (d) Population having septic tank / pit privy facilities. : Signature(s): Name of the Applicant(s): *******. Address of Applicant(s): *********. *****************. ****************. ********************.