FORM I (See rule 8) APPLICATION FOR AUTHORISATION/RENEWAL OF AUTHORISATION (To be submitted in duplicate) To, The Member Secretary, Meghalaya State Pollution Control Board Arden, Lumpyngngad, Shillong-793014 1. Particulars of the Applicant (i). Name of the Applicant: (in block letters & in full) (ii). (iii). (iv). Name of the Institution : Address: Tele No: Fax No: Telex No: Bed capacity(in case of hospitals/nursing homes): Number of patients provided services / Number of Samples received per month(in case of clinics,dispensary,pathological lab etc): 2. Activity for which authorization is sought (Tick appropriately): (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 authorization 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(if any) of bio-medical waste: (ii). Mode(s) of treatment: 6. Brief description of treatment and disposal (attach details): 7. (i). Category of waste to be handled (see attachment): (ii). Quantity of waste (category wise) to be handled per month(attach details): 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. I do also hereby undertake to provide any further information sought by the prescribed authority in relation to these rules and to fulfill any conditions stipulated by the prescribed authority. Date: Signature of the applicant Place: Designation of the applicant CATEGORIES OF BIO-MEDICAL WASTES Waste Category No. Waste Category Type Waste generation per month(kg) Treatment and disposal Option adopted No.1 Human Anatomical Waste (human tissues, organs, body parts) No.2 Animal Waste (animal tissues, organs, body parts carcasses, bleeding parts, fluid, blood and experimental animals used in research, waste generated by vetinary hospitals, colleges, discharged from hospitals, animal houses) No.3 Microbiology & Biotechnology Wastes (wastes from laboratory cultures, stocks or specimens or micro-organisms live or attenuated vaccines, human and animal cell culture used in research and infectious agents from research and industrial laboratories, wastes from production of biologicals, toxins, dishses and devices used for transfer of cultures) No.4 Waste sharps (needles, syringes, scalpels, blades, glass etc. that may cause puncture and cuts. This includes both used and unused sharps) No. 5 Discarded medicines and Cytotoxic drugs (wastes comprising of outdated, contaminated and discarded medicines) No. 6 Soiled Waste (items contaminated with blood, and body fluids including cotton, dressings, soiled plaster casts, lines beddings, other material contaminated with blood) No. 7 Solid Waste (wastes generated from disposal items other than the waste sharps such as tubings, catheters, intravenous sets etc. No. 8 Liquid Waste (waste generated from laboratory and washing, cleaning, house-keeping and disinfecting activities) No. 9 Incineration Ash (ash from incineration of any bio- medical waste) No. 10 Chemical Waste (chemicals used in production of biologicals, chemicals used in disinfection, as insecticides etc.) Name: Designation: Seal:
