FORM IV B APPLICATION FOR RENEWAL OF CONSENT FOR CONTINUING DISCHARGE OF SEWAGE/TRADE EFFLUENT UNDER SECTION 25/26 OF THE WATER (PREVENTION AND CONTROL OF POLLUTION) ACT, 1974 (To be submitted in triplicate) Date: From To The Member Secretary, Kerala State Pollution Control Board, Pattom P.O., Thiruvananthapuram -695 004. Sir, I hereby apply for Renewal of Consent under Section 25/26 of the Water (Prevention and Control of Pollution) Act, 1974 to continue discharge of sewage/trade effluent from .. in accordance with the details given below. 1. Name and address of the industry : 2. Name and address of the Occupier : 3. Details of consent granted: Consent No. Date of issue Valid upto 4. Capital Investment: 5. Details of consent fee remitted: 6. Details of changes in data reported in the previous application (a) Raw materials used: (b) Production process: (c) Products and by products: (d) Water consumption (in litres/day): (e) Quantity of effluent/sewage: Sl. No. Name of material Process where used Consumption In tonne/day Sl. Name of products Quantity in No. and by -products tonne/day Boiler Cooling Domestic Process Others (specify) Total (f)Outlet location : (Please furnish drawing showing the new location of outlet) (g) Effluent/sewage discharged into : 7. Compliance with specified standards : (Copy of analysis report of effluent taken within the previous 6 months to be attached) 8. Details of additional treatment facilities provided/proposed : 9. Any other additional information : 10. I hereby declare that the information furnished above is correct to the best of any knowledge. 11. I hereby agree to submit to the Board application for renewal of consent three months in advance of expiry of the period consented to for discharge if to be continued thereafter. 12. I undertake to furnish any information within one month of its being called for by the Board. I further understand that the date on which all the relevant particulars in order to make the application complete in all respects are furnished by me will be reckoned as the date of making the application. Signature: Name: Designation of the Occupier: Note: This downloaded form will be considered only if Rs. 100/-is remitted as cost of the application form along with consent fee. The amount should be remitted as cash or DD drawn in favour of the Kerala State Pollution Control Board, Thiruvananthapuram.
