Sr. No. Rs.25/- Form-I [ See Rule 3(b) 5(2), (3) and (6) (ii)] APPLICATION FOR AUTHORISATION/RENEWAL OF AUTHORISATION FOR COLLECTION/ RECEPTION/TREATMENT/ TRANSPORT/ STORAGE/ DISPOSAL OF HAZARDOUS WASTES. From __________________________ __________________________ __________________________ To The Member Secretary, Himachal Pradesh State Environment Protection & Pollution Control Board, Paryavaran Bhawan, Phase-III, Shimla-171009. Sir, I/ We apply fro authorisation /Renewal of Authorisation under sub-rule (3) of Rule 5 of the Hazardous Wastes (Management and Handling) Rules, 1989 for collection/ reception/ treatment/ transport/ storage/disposal of hazardous wastes. TO BE FILLED BY APPLICANT FOR OFFICE USE ONLY 1. Code No.: 2. Whether the unit is situated in a critically Polluted area as identified by Ministry of Environment & Forests: PART A-GENERAL: 3. (a) Name of Owner/Occupier: (b) Name and address of the unit and location of activity: (c) Authorisation required for (Please tick mark appropriate activity/activities) (i) Collection. (ii) reception (iii) Treatment. (iv) Transport. (v) Storage. (vi) Disposal. (d) In case of Renewal of authorisation, previous Authorization Number and date. 4. (a) Whether the unit is generating the hazardous waste as defined in the Hazardous Wastes ( Management & Handling) Rules, 1989 and amendments made thereunder, (b) If so type and quantity of waste. 5. (a) Total capital invested on the project: (b) Year of commencement of production: (c) Whether the industry works general/ 2 shifts/ round the clock: 6. (a) List and quantum of products and bye-products: (b) List and quantum of raw materials used: 7. Furnish a flow diagram of manufacturing process input and output in terms of products and waste generated including for captive power generation and demineralised water: PART B -PERTAINING TO SEWAGE AND TRADE EFFLUENT: 8. Quantity and source of water for, (a) Cooling m3/d. (b) Process m3/d. (c) Domestic use m3/d (d) Others m3/d. Page 1 of 4Sr 7/16/08http://hppcb.gov.in/hazardousforms.htm FORM-3 [See Rule 9(1)] FORMAT FOR MAINTAINING RECORDS OF HAZARDOUS WASTES AT THE FACILITY 1. Name and address of the occupier or operator of a facility: 2. Date of issuance of authorization and its reference number: Place: Signature Date: Designation 9. Sewage and trade effluent discharge: (a) Quantum of discharge m3/d. (b) Is there any effluent treatment plant. (c) If 'yes', a brief description of unit operations with capacity. (d) Characteristics of final effluent-pH. Suspended solids. Dissolved solids. Chemical Oxygen Demand (COD). Biochemical Oxygen Demand (BOD5// 20ºC/ BOD3// 27ºC Oil and grease. (Additional parameters as specified by the concerned Pollution Control Board). (e) Mode of disposal and final discharge point (Enclose map showing discharge point. (f) Parameters and frequency of self- monitoring. PART C-PERTAINING TO STACK (CHIMNEY) & VENT EMISSION: 10 (a) Number of stacks and vents with height and dia (m). (b) Quality and quantity of stack emission from each of the above stacks-particulate matter and Sulphur Dioxide (SO2) (Additional parameters as specified by the concerned Pollution Control Board). (c) A brief account of the air pollution control unit to deal with the emission. (d) Parameters and frequency of self- monitoring. PART D - PERTAINING TO HAZARDOUS WASTE AND HAZARDOUS CHEMICALS: 11. Solid wastes. (a) Total quantum of generation. (b) Quantum of hazardous waste generated and its nature, as defined under the Environment (Protection) Act, 1986. (See the Hazardous Waste (Management and Handling) Rules, 1989. (c) Mode of storage within the plant, method of disposal and any other information sought by the concerned Pollution Control Board. 12. (a) Hazardous chemicals as defined under Environment (Protection) Act 1986, (See the Manufacture, Storage and Import of Hazardous Chemicals Rules, 1989). (b) Whether any isolated storage is involved if 'yes', attach details. (c ) Whether emergency plans are prepared for taking . -On -site measures. -Off-site measures. Page 2 of 4Sr 7/16/08http://hppcb.gov.in/hazardousforms.htm 3. Description of hazardous waste: 4. Description of storage and treatment of hazardous waste: 5. Details of transportation of hazardous waste: 6. Details of disposal hazardous waste: 7. Data on environmental surveillance: Physical form with description Chemical form Total volume and weight (in kg.) Date Method of storage of hazardous wastes Date Method of treatment of hazardous wastes Name and address of the consignee of package Mode of packing/ of the waste for transportation Mode of transportation to site of disposal Date of transportation. Date of disposal Concentration of hazardous material in the final waste form Sit of disposal (identify the location on the relevant layout drawing for reference) Method of disposal Persons involved in disposal Date of measurement Analysis of ground water Analysis of soil samples Analysis of air sampling Analysis of any other samples (give details) Location of sampling Depth of sampling Data Location of sampling Depth of sampling Data Location of sampling Data Page 3 of 4Sr 7/16/08http://hppcb.gov.in/hazardousforms.htm 8. Details of Hazardous waste reused and recycled: Place: Signature Date: Designation FORM-4 [See Rule 9(2)] FORMAT FOR THE SUBMISSION OF RETURNS, REGARDING DISPOSAL OF HAZARDOUS WASTE 1. Name and address of the institution: 2. Details of waste disposal operation: (Attach a sketch showing the locations(s) of disposal) 3. Data on environmental surveillance: Place: Signature Date: Designation HOME Date Total quantity of hazardous generated Details of hazardous waste minimum activity. Material received Final Quantity of waste generated Net reduction in waste generation quantity & %age. Date of issuance of Authorisation for the disposal of hazardous waste and its Ref. Number Description of Hazardous Waste Mode of transportation to the site of disposal * Site of disposal Brief description of the method of disposal Date of disposal Remark (if any) Physical form and contents Chemical form Total vol. Of the Hazardous Waste disposed with No of packages Date of measurement Analysis of ground water samples Analysis of soil samples Analysis of air sampling Analysis of any other samples (give details) Location of sampling Depth of sampling Data Location of sampling Depth of sampling Data Location of sampling Data Page 4 of 4Sr 7/16/08http://hppcb.gov.in/hazardousforms.htm
