(Lan —ar 34) sare eT : ETT 3 FORM 1 [See rutes 5{3) and (7)} APPLICATION FOR OBTAINING AUTHORISTION FOR COLLECTION/RECEPTION/TREATMENT/TRANSPORT/STORAGE (DISPSOAL OF HAZARDOUS WASTE* From: .. To The Member Secretary, Pollution Control Board... Pollution Contra! Committee, Sir, 1/ We hereby apply for authorisation/cenewal of authorisation under sub-rule (3) of Rule 5 of the Hazardous Waste ( Management, Handling and Transboundary Movement) Rules, 2008 for collection/reception/treatment/ transporvstorage/disposal of hazardous wastes. For Office Use Only Code No. 6. Whether the unit is situated in a critically polluted area as identified by Ministry of Environment and Forests; To be filled in by Applicant Pari A: General 3 (a) Name and address of the unit and location of activity (b) Authorisation required for ( Please tick mark appropriate activity / activities collection reception treatment transport storege disposal (©)__In case of renewal of auth ‘delete whichever is not applicable 3718 GW08—15re) HE GAZETTEOF INDIA: EXTRAORDINARY. Liaw See 3 4, (a) Whether the unit is generating hazardous waste as defined in these Rules (b) If so the type and quantity of wastes ¢ in Tonnes/K!.) $. (a) Total capital invested on the project { in Rupees) (b) Year of commencement of production (©) Whether the industry works general! 2 shifts’ round the clock 6. (a) List and quantum of produets and by-products (in Tonnes/KI.) (6) List and quantum of raw material used (in Tonnes/KL) Furnish a flow diagram of manufacturing process showing input and output in terms of products, waste generaled including far captive power gencralion and deminetalised water Pari B: Hazardous Waste 8. Hazardous Wastes: (a) Type of hazardous wastes generated as defined under these Rules (b) Quantum of hazardous waste generated {©} Sources and waste characteristics (Also indicate wastes amenable to recycling, re-processing and reuse) (@) Mode of storage within the plant, method of disposal and capaci details). (provide 9. Hazardous Wastes generated as per these Rules ftom storage of hazardous chemicals as defined under the Manufacture, Storage and Import of Hazardous Chemicals Rules, 1989 Pari C: Treatment, Storage and Disposal Facility 10, Detailed proposal of the facility (to be attached) to include @ Location of site (provide map) i) Name of waste processing technology Details of processing technology Gv) Type and Quantity of waste to be processed per day (v) Site clearance (from local authority, if any) (vi) Uiilization programme for waste processed (Product Utilization): (vit) Method of disposal (details in brief'be given) (viii) Quantity of waste to be disposed per day (ix) ‘Nature and composition of waste (x) Methodology and operational details of land filling’ incineration (xi) Measures to be taken for prevention and control of environmental pollution including treatment of leachate (xii)__Investment on Project and expected returns (xiii) Measures to be taken for safety of workers working in the plant Place: Signature: .... Date : Designation : ..esseesc00