Rs.10/- FORM-I (See Rule-8) APPLICATION FOR AUTHORISATION / RENEWAL FOR COLLECTION/RECEPTION/TREATMENT/TRANSPORT/STORAGE/ DISPOSAL OF BIO-MEDICAL WASTE (TO BE SUBMITTED IN DUPLICATE) To The Member Secretary, Himachal Pradesh State Environment Protection & Pollution Control Board, Paryavaran Bhawan, Phase-III, Shimla-171009 1. Particulars of Applicant: (i) Name of the Applicant: (In block letters & in full) (ii) Name of the Institution: Address: Tel No., Fax No.: 2. Activity for which authorization is sought: (i) Generation. (ii) Collection. (iii) Reception. (iv) Storage. (v) Transportation. (vi) Treatment. (vii) Disposal. (viii) Any other form of handling. 3. Please state whether applying for fresh authorization or for renewal: (In case of Renewal, previous Authorisation- Number and date). 4. (i) Address of the institution handling Bio- Medical Wastes: (ii) Address of the place of the treatment facility: (iii) Address of the place of disposal of the waste: 5. (i) Mode of transportation (in any) of the Bio-Medical waste: (ii) Mode(s) of treatment: 6. Brief description of method of treatment and disposal (Attach details): 7. (i) Category (see Schedule-I) of waste to be handled: (ii) Quantity of waste (category-wise) to be handled per month: 8. Declaration I do hereby declare that the statements made and information given above are true to the best of my knowledge and belief and that I have not concealed any information. Page 1 of 2Rs 7/16/08http://hppcb.gov.in/Downloads/Biomedical_form.htm To be submitted with Form 1 NAME OF THE HEALTH CARE FACILITY: Signature of the Head of the Health Care Facility BACK I do also hereby undertake to provide any further information sought by the prescribed authority in relation these rules and to fulfill any conditions stipulated by the prescribed authority. Date: Signature of the applicant Place: Designation of the applicant CATEGORY WISE QUANTUM OF WASTE GENERATED IN KG/LT PER MONTH Human Anatomical waste (1) Animal Waste (2) Microbiology Waste (3) Waste Sharps (4) Discarded Medicines and Drugs (5) Solid waste (infectious) (6) Solid waste (non- infectious) (7) Liquid Waste (8) Incineration Ash (9) Chemical Waste (10) Total CATEGORY WISE TREATMENT GIVEN TO THE WASTE GENERATED IN TABLE (A) Human Anatomical waste (1) Animal Waste (2) Microbiology Waste (3) Waste Sharps (4) Discarded Medicines and Drugs (5) Solid waste (infectious) (6) Solid waste (non-infectious) (7) Liquid Waste (8) Incineration Ash (9) Chemical Waste (10) (C) NUMBER OF TREATMENT EQUIPMENTS (WITH CAPACITY) AVAILABLE No. of Beds Functional Incinerator Single or Double Chamber Capacity of Incinerator Air Pollution Control Devices in Incinerator Autoclave Microwave/ Hydroclave Shredder Needle Cutter (D) DEEP BURIAL (IF ADOPTED) Number of Patients treated/Number of samples tested from 1st April, 07 to 31st March, 08 Site of burial Size & Depth of the Pit Method adopted for burial Page 2 of 2Rs 7/16/08http://hppcb.gov.in/Downloads/Biomedical_form.htm
