SCHEDULE-I

Common Application for Consent under

Water (Prevention and Control of Pollution) Act, 1974,
Air (Prevention and Control of Pollution) Act, 1981) and authorisation under
Hazardous Wastes (Management and Handling) Rules, 1989, as amended

No. .....................
Accompanying form in triplicate to be submitted by
the applicant. One copy may be retained by the
applicant.

Explanatory note for filling in application form for

Consent / Authorisation

(1) Any applicant knowingly giving incorrect information or suppressing any information
pertaining to any of the items of the application shall be liable for punishment as per
provisions under the relevant Act.

(2) The application form shall be submitted at the head-quarter office of the Board at the
address given on the first page of the application form or to the respective Zonal or
Regional or Sub-Regional office or District Office of the Board / Pollution Control
Committee under whose jurisdiction the applicants activity falls.

(3) The application shall be accompanied by the consent fee in the form of Demand Draft in
favour of ...................:..................... State Pollution Control Board / Pollution Control
Committee. Fee paid is not refundable.

(4) For the items marked * strike out which is not relevant.

(5) If any of the items is not relevant to the activity of the applicant, please state 'Not
Applicable'.

(6) If the space for reply provided for any item is inadequate, use additional sheets, duly
referenced.

(7) Item 1 : Give the name of the person who is authorised by the applicant to transact their
business.

(8) Item 2 : Also state the concerned institutions under whose administrative area the unit
falls.

(9) The form shall be accompanied by the relevant documents specified. on the last page of
the application form.

(10) Capital Investment - Consent fee is to be paid based on gross fixed capital investment of
the unit without depreciation till the date of application. The gross capital investment shall
include cost of ""land, building, plant and machinery without depreciation.
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Application form for Consent / Authorisation

From : .................................. ..................................

.................................. ..................................
.................................. ..................................
.................................. ..................................

To
The.......................................................................
...................................... Pollution Control Board
.......................................................................

Sir,

I / We hereby apply for *

(i) Consent to Establish / Operate / Renewal of consent under section 25 and 26 of the Water
(Prevention and Control of Pollution) Act, 1974, as amended.

(ii) Consent to establish / operate / renewal of consent under Section 21 of the Air (Prevention
and Control of Pollution) Act, 1981, as amended.

(iii) Authorisation / renewal of authorisation under rule 5 of the Hazardous Wastes

(Management and Handling) Rules, 1989, as amended in connection with my / our existing
/ proposed / altered / additional manufacturing ! processing activity from the premises as
per the details given below.

Part A : General

1. Name, designation, office address with

telephone, fax numbers, e-mail of the
applicant / occupier / Industry / Institution/
Local Body :

2.(a) Name and location of the industrial

unit / premises for which the application
is made. (Give revenue Survey Number /
plot number, name of Taluka and District,
also telephone and fax number) :

(b) Details of the planning permission

obtained from the local body / Town and
Country Planning authority / metropolitan
development authority / designate
authority :

(c) Name of the local body under whose

jurisdiction the unit is located and name
of the licence issuing authority :
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3. Names, addresses with telephone and fax

number of Managing Director/Managing
Partner and officer responsible for
matters connected with pollution
control and / or hazardous waste disposal. :

4. (a) Are you registered as a small-scale

industrial unit ? :

(b) If yes, give the number and date of

registration. :

5. Gross capital investment of the unit

without depreciation till the date of
application (Cost of building, land,
plant and machinery). :

(To be supported by an affidavit,

Annual Report or certificate
from a Chartered Accountant. For
proposed unit(s), give estimated figure) :

6. If the site is located near sea-shore / river

bank / other water bodies; indicate
the distance and the name
of the water body, if any. :

7. Does the location satisfy the requirements

under relevant Central / State Govt.
notifications such as Coastal Regulation Zone,
Notification on Ecologically Fragile Area,
Industrial location policy, etc. If so,
give details. :

8. If the site is situated in notified industrial

estate,

(a) whether effluent collection, treatment

and disposal system has been provided
by the authority

(b) will the applicant utilise the system,

if provided

(c) if not provided, details of proposed

arrangement.

9. Total plot area, built-up area and area

available for the use of treated
sewage / trade effluent :

10. Month and year of proposed commissioning

of the unit :

11. Number of workers and office staff. :

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12. (a) Do you have a residential colony

within the premises in respect of
which the present application is
made ? :

(b) If yes, please state population staying :

(c) Indicate its location and distance

with reference to plant site. :

13. List of products and by-products

manufactured in tonnes / month,
kl / month or numbers / month
(Give figure corresponding to
maximum installed production capacity) :

14. List of raw materials and process chemicals

with annual consumption corresponding
to above stated production figures, in tonnes /
month or kl / month or numbers / month. :

15. Description of process of manufacture for each

of the products showing input, output, quality
and quantity of solid, liquid and gaseous wastes,
if any from each unit process.
(To be supported by flow sheet and / or
material balance and water balance sheet). :

Part B : Waste water aspects

16. Water consumption for different uses (m3 / day) :

(i) Industrial cooling, spraying –

in mine pits or boiler feeds.

(ii) Domestic purpose -

(iii) Processing whereby water -

gets polluted and the
pollutants are easily
biodegradable

(iv) Processing whereby water gets

polluted and the pollutants
are not easily bio-degradable
and are toxic

(v) Others such as agriculture,

gardening etc. (specify)

Total : ……………………………
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17. Source of water supply.

Name of authority granting permission
if applicable and quantity permitted :

18. Quantity of waste water (effluent) generated

(m3 / day)

(i) Domestic : (v) Boiler Blowdown :

(ii) Industrial : (vi) Cooling water blowdown :

(iii) Process : (vii) DM Plant / Softening

Plant washings :

(iv) Washings :

19. Water budget calculations accounting

for difference between water consumption
and effluent generated. :

20. Present treatment of sewage / canteen

effluent (Give sizes / capacities of
treatment units). :

21. Present treatment of trade effluent

(Give sizes / capacities of treatment units).
(A schematic diagram of the treatment
scheme with inlet / outlet characteristics
of each unit operation / process is to be
provided. Include details of residue
management system (ETP sludges)) :

22. (a) Are sewage and trade effluents

mixed together ? :

(b) If yes, state at which stage –

Whether before, intermittently or
after treatment. :

23. Capacity of treated effluent sump. Guard

Pond if any.

24. Mode of disposal of treated effluents, with

respective quantity, m3 / day

(i) into stream / river (name of river) :

(ii) into creek / estuary

(name of creek/estuary) :
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(iii) into sea :

(iv) into drain / sewer (owner of sewer) :

(v) On land for irrigation on owned land /

lease land. Specify cropped area.
(To be supported by relevant documents) :

(vi) Quantity of treated effluent reused /

recycled, m3 / day
Provide a location map of disposal
arrangement indicating the outlet (s)
for sampling :

(vii) Provide a location map of disposal

arrangement indicating the outlet (s)
for sampling :

25. (a) Quality of untreated / treated effluents

(Specify pH and concentration of SS,
BOD, COD and specific pollutants
relevant to the industry. TDS to be reported
for disposal on land or into stream / river). :

(b) Enclose a copy of the latest report of

analysis from the laboratory approved by
State Board / Committee / Central Board /
Central Government in the Ministry of
Environment & Forests. For proposed unit
furnish expected characteristics of the
untreated / treated effluent. :

Part - C : Air emission aspects

26. Fuel consumption :

Coal LSHS Furnace Natural Others

Oil gas (Specify)
(a) Fuel consumption (TPD / KLD)

(b) Calorific value

(c) Ash content %

(d) Sulphur content %

(e) Other (specify)

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27. (A) Details of stack (process & fuel stacks):

(a) Stack number (s) : 1 2 3 4

(b) Attached to :
(c) Capacity : :
(d) Fuel type :
(e) Fuel quantity (TPD / KLD) :
(fl Material of construction :
(g) Shape (round / rectangular) :
(h) Height, m (above ground level) :
(i) Diameter / size, in meters :
j) Gas quantity, Nm3 / hr. :
(k) Gas temperature, 0C :
(1) Exit gas velocity, m / sec. :

(m) Control equipment preceding the stack :

(Attach specifications including residue

management systems of each of the control
equipment indicating inlet / outlet concentrations
of relevant pollutants) :

27. (B) Whether any release of odoriferous

compounds such as Mercaptans, Phorate
etc. are coming out :

28. Do you have adequate facility for collection

of samples of emissions in the form of port
holes, platform, ladder etc. as per Central Board
Publication "Emission Regulations Part-III"
December 1985) :

29. Quality of treated flue gas emissions and

process emissions.
(Specify concentration of criteria pollutants and
industry / process-specific pollutants
stack-wise. Enclose a copy of the latest
report of analysis from the approved
laboratory by State Board / Central Board /
Central Government in the Ministry of
Environment and Forests. For proposed units
furnish the expected characteristics of the
emission :

Part - D : Hazardous waste aspects

30. (a) Whether the unit is generating

hazardous waste as defined in the
Hazardous Waste (Management and
handling) Rules, 1989, as amended. :

(b) If so, the category No. :

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31. Authorization required for *

(i) Collection :

(ii) Reception :

(iii) Treatment :

(iv) Transport :

(v) Storage :

(vi) Disposal
of the hazardous waste :

32. Quantity of hazardous waste generated

(kg / day) or (mt / month) :

33. Characteristics of the hazardous waste(s).

Specify concentration of relevant pollutants.
Enclose a copy of the latest report
of analysis from the laboratory approved by
'State Board/Central Board/ Central Government
in the Ministry of Environment and Forests).
For proposed units furnish expected
characteristics. :

34. Mode of storage (intermediate or final)

(describe area, location and methodology). :

35. Present treatment of hazardous waste, if any

(give type and capacity of treatment units) :

36. Quantity. of hazardous waste disposed

(i) Within the factory :

(ii) Outside the factory

(Specify location and enclose
copies of agreement) :

(iii) Through sale (Enclose documentary

proof and copies of agreement) :

(iv) Outside State / Union Territory, if yes

particulars of (i) & (iii) above :

(v) Other (specify) :

Part - E : Additional information

37. (a) Do you have any proposals to

upgrade the present system for
treatment and disposal of effluent/
emission and / or hazardous waste :
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37. (b) If yes, give the details with

time-schedule for the implementation
and approximate expenditure to be
incurred on it. :

38. Capital and recurring (O & M) expenditure

on various aspects of environment
protection such as effluent, emission,
hazardous waste, solid waste, tree
plantation, monitoring, date acquisition
etc. (give figures separately for items
implemented / to be implemented). :

39. To which of the pollution control

equipment, separate meters for
recording consumption of electric energy
are installed ? :

40. Which of the pollution control items

are connected to D.G. set (captive power
source) to ensue their running in the event
of normal power failure ? :

41. Nature, quantity and method of disposal

of non-hazardous solid waste generated
separately from the process of manufacture
and waste treatment. (Give details of
area / capacity available in applicant's land) :

42. Hazardous Chemicals - Give details of

chemicals and quantities handled
and stored. :

(i) Is the unit a Major Accident

Hazard unit as per MSIHC Rules ?

(ii) Is the unit an isolated storage

as defined under the MSIHC Rules ?

(iii) Indicate status of compliance of

Rules 5, 7, 10, 11, 12, 13 and 18 of
the MSIHC Rules.

(iv) Has approval of site been obtained

from the concerned authority ?

(v) Has the unit prepared an Off-site

Emergency Plan ? Is it updated ?

(vi) Has information on imports of

chemicals been provided to the
concerned authority ?

(vii) Does the unit posses a policy

under the PLI Act?
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43. Brief details of tree plantation / green

belt development within applicant’s
premises (in hectres). :

44. Information of schemes for waste

minimisation, resource recovery and
recycling - implemented and to be
implemented, separately. :

45. (a) The applicant shall indicate whether

industry comes under Public Hearing,
if so, the relevant documents such as
EIA, EMP, Risk Analysis etc. shall be
submitted, if so, the relevant documents
enclosed shall be indicated accordingly. :

(b) Any other additional information that

the applicant desires to give. :

46. I / We further declare that the information furnished above is correct to the best of my / our
knowledge. :

47. I / We hereby submit that in case of any change from what is stated in this application in
respect of raw materials, products, process of manufacture and treatment and / or disposal
of effluent, emissions, hazardous wastes etc. in quality and quantity; a fresh application for
Consent / Authorisation shall be made and until the grant of fresh Consent / Authorisation
no change shall be made.

48. I / We undertake to furnish any other information within one month of its being called by
the Board / Committee.

49. I / We agree to submit to the Board an application for renewal of consent / authorisation in
two months in advance before the date of expiry of the consent / authorisation validity
period:

50. I / We enclose herewith a Demand Draft for Rs. ....................................................................

(Rupees........................................................................................................) drawn in favour
of ............................... Pollution Control Board / Committee as the fee for consent /
authorisation for a period upto .......................................................... .

Yours faithfully,

Signature ...................................
Name .........................................
Designation ...............................

Documents enclosed :