Download Application Form for Obtaining Consent to Establish Business

Page 1 of 11 FORM I (a) & IV (a) (See Rule 10 of Air Act & Rule 29 of Water Act) APPLICTION FORM FOR OBTAINING CONSENT TO ESTABLISH (under section 21 of the Air (Prevention and Control of Pollution) Act, 1981 (14 of 1981) and section 25/26 of 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, (1) I / We hereby apply for consent to establish under section 21 of the Air (Prevention and Control of Pollution) Act, 1981 (14 of 1981) and section 25/26 of the Water (Prevention and Control of Pollution) Act, 1974. (2) The annexure, appendices, other relevant particulars and plans are submitted herewith. (3) 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. (4) 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. (5) I/We understand that the factory / unit can be put in operation only on obtaining CONSENT TO OPERATE as per the provisions of section 21 of the Air Page 2 of 11 (Prevention and Control of Pollution) Act, 1981 (14 of 1981) and /or section 25/26 of the Water (Prevention and Control of Pollution) Act, 1974 (6 of 1974). (6) Accordingly, I/we undertake that the production including the trial production shall not be conmmenced until and unless :- (a) All the conditions which may be set out in the grant of consent to establish and complied with. (b) Consent to operate under the Air (Prevention and Control of Pollution) Act, 1981 and /or Water (Prevention and Control of Pollution) Act, 1974 or any other relevant Act is obtained. (7) I/We understand that any condition imposed by the Board while granting consent to establish will be binding on me/my company. I / We enclose herewith the deposit Slip No. ,for Rs. ****0.00 (Rupees ******* only) of amount paid into Oriental Bank of Commerce, Dempo Tower, EDC Plaza, Patto Panaji Goa and credited to the account No. 1726 of Goa State Pollution Control Board, Panaji as Fees** payable under section 21 of the Act, 1981. Yours faithfully Signature : Name of the applicant: Mr. ----. ----, ----. ----, ----. Address: -----. ----. ----. ----. *Strike out which is not relevant **Please see Table. Page 3 of 11 ANNEXURE TO FORM I (a) 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. GENERAL 1.1 Name of the Industry : 1.2 Location of the proposed Industry : 1.3 Address for Correspondence : 1.4 Name and address of Applicant with Telephone Number : . 1.5 Nationality of the Applicant : 1.6 Status of the applicant : (a) Individual : (b) Proprietary : © Partnership Firm (Whether registered or unregistered) : (d) Joint family Concerned : (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.) : Page 4 of 11 (i) Any other Association or Body : No District : Taluka : Town : Village : Revenue Survey No. : 1.7 Give Revenue / Survey Number of land / Premises for which the application is made stating District, Taluka and Village. : Area in Hectares : (1) Setting up of new industry. 1.8 Purpose for which consent is required : (2) Expansion (R & T Laboratory) / Diversification / Modifications If it is for expansion / diversification / modifications, please furnish details. 1.9 (a) Total cost of the project (including cost of land) : (b) Total estimated investment (including cost of land) : 1.10 Number and date of provisional Registration issued by Directorate of Industries and Mines for SSI units : 1.11 Date of submission of application to HPCC in case of Large/Medium Scale Industries : 1.12 Number of workers to be employed : 2. PRODUCTS AND RAW MATERIALS 2.1 List of products and by-products if any, with proposed quantity to be produced per month : Licensed capacity Installed capacity 2.2 List of raw materials used. Quantity per month (Quantity / Refer Annexure I. Page 5 of 11 Quantity per month (Quantity / month). 3. MANUFACTURING PROCESS 3.1 Give detailed description of manufacturing process along with a process flow diagram showing the entry and exit points of all raw materials, intermediate products, by- products, water pollution sources. : 3.2 Have you any foreign collaboration? : 4. SOURCE OF ENERGY Existing sources of energies will be used for this product 4.1 Power Load : 4.2 D.G. Set : 4.3 Boiler 4.4 Type of fuel used : Name Quantity MTl/month (a) Wood (b) Coal ( c)LSHS (d) Furnace Oil (e) LDO (f) HSD (g) Kerosene (h) Naphtha (i) Other (specify) Page 6 of 11 5. WATER CONSUMPTION 5.1 Source of supply of water (m3/day) : 5.2 State daily quantity of water use in Kilo liters for the Research & technology lab. : 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) Water consumption in fume cupboard 6. WASTE-WATER GENERATION 6.1 State daily quantity of waste - water generated from Research & technology lab in Kilo liters : 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. Page 7 of 11 (f) D. M Water. (g) Agriculture. (h) Spray in mines. (i) Other uses 6.2 Do you propose to recirculate any or all the above waste streams, If yes, give details. : Yes / No 6.3 Whether effluents need any treatment? : Yes / No If yes, give details of proposed waste-water treatment plant, schematic diagram, flow sheet or detailed engineering drawing along with design details, as the case may be. 6.4 Final point of disposal of waste- water Give name of river, nallah, pond or survey number of land along with site clearance) : 6.5 Attach Water Balance Sheet : 6.6 Indicate characteristics of waste- water to be discharged before and after treatment. : (a) PHYSICAL Treatment : pH : Colour : Odour : Total Suspended Solids (mg/l) : (b) CHEMICAL BOD (mg/l) : COD (mg/l) : Page 8 of 11 Oil & Grease (mg/l) : Sulphates (mg/l) : Metals like Nickel, Zinc, Tin, Chromium & Cyanide : ( c) Is there any discharge of specific toxic substances ? : 7. SOLID WASTE 7.1 Total quantity of solid Waste (ton/month) : 7.2 Characteristics of solid waste : Packing material, rejected formulation powder etc. (a) Incineration (b) Land filling ( c) Sale (d) Composting 7.3 Methods proposed for Treatment and disposal : (e) Any other method 8. AIR POLLUTION 8.1 Give details of air pollution sources such as process emissions, reaction on vessels, crushers, grinders, pulverisers, furnaces, boilers, power generation sets, incinerators, etc. Control equipment's, chimney/vents proposed for stacks. Chimneys and vents diameter and height above ground level/roof level should be given for each of them. : 8.2 Details of air pollution control measures with schematic diagram, flow sheet/detailed engineering diagrams, as the case may be, with respect to stack/chimney specifications, scrubber, ESP, bag filter, etc. : Page 9 of 11 9. NOISE POLLUTION 9.1 Give details of source of noise pollution such as process machinery, D. G. sets, grinders ball mills, etc and measures taken for control of noise from each of noise pollution sources. : 10. Is there any odour problem like to occur from your industry? : 11. POLLUTION CONTROL MANAGEMENT 11.1 Expenditure proposed for Capital Recurring (a) Water pollution control : (b) Air Pollution Control : © Disposal Arrangements : (d) Solid Waste Handling : (e) Pollution Monitoring : 11.2 Total capital investment proposed on pollution control as a percentage of total investment of the industry. : 11.3 Give the details of the organization proposed to be set up by you for the control of pollution. : 12. Any other additional information about beneficial or adverse environment impact from your industry. : - Yours faithfully, Signature(s): Name of the Applicant(s): _________________________ Page 10 of 11 Address of Applicant(s): ____________________________ ____________________________ ____________________________ ____________________________ ____________________________ Page 11 of 11 13. ACCOMPANIMENTS : Following documents should invariably be attached: 1. Land allotment / earmarking letter or lease / Sale deed. 2. Provisional registration in case of SSI. 3. Approval of VP / Municipality (Not required for units to be set up in industrial estates.) 4. Flow chart and detailed production process. ? 5. A copy of Project Report for projects costing one crore and above. 6. Site plan (not required for units to be set up in Industrial Estates.) ? 7. Layout plan showing the location of manufacturing equipments, water supply / drainage lines, position of chimneys, effluent treatment plant and final discharge point, sludge solid waste disposal points and septic tanks / soak pits. 8. For medium and large-scale units, environmental impact assessment and oceanographic or other survey, if required will have to be furnished in the prescribed time limit. 9. Site plan showing surrounding residential area, public places, water stream etc., of the factory site within a radius of 5 kms with wastewater treatment and disposal systems clearly indicating where waste-0water is proposed to be disposed off (for medium and large scale units). ? 10. Affidavit on stamp paper of value Rs. 20/- or Certificate from Chartered Accountant certifying the Gross Fixed Asset Value. 11. Original authorisation letter of the person to whom authorization is made to sign this application form except individual proprietary concern.