FORM 5 [See rule 8(1) ] FORM OF APPLICATION FOR GRANT/RENEWAL OF REGISTRATION OF INDUSTRIAL UNITS POSSESSING ENVIRONMENTALLY SOUND MANAGEMENT

FACILITIES FOR REPROCESSING/RECYCLING {To be submitted to the Central Pollution Control Board in triplicate by the Reprocessor/Recycler} Name and Address of the unit : Name of the occupier or o!ner of the unit !ith desi"nation# Tel / $a%: 'ate of commissionin" of the unit : No) of !or*ers + includin" contract labourers , : Consent .alidity a, /ater +Pre0ention 1 Control of Pollution, Act# 123( 0alid up to444444444 b, Air +Pre0ention 1 Control of Pollution, Act# 1251 0alid up to444444444 Product 7anufactured durin" the Year Name of the " a#t$t% last three years +Tonnes / 8ear , Prod !t $# Metr$! To##e& or 'L a, b, c, Ra! material consumption durin" last three years +Tonnes/ year, Year Name of the " a#t$t% Ra( Mater$a) $# Metr$! To##e& or 'L !o#& med a, b, c,

1 & () -

6)

3)

5) 2) 1: 11 1

7anufacturin" Process

Please attach manufacturin" process flo! dia"ram for each product +s, /ater Consumption 9ndustrial 4444444444m&/ day 'omestic4444444444))m&/day /ater Cess paid up to +date, 444444)) /aste !ater "eneration as per 9ndustrial/'omestic consent444)))m&/day Actual444m&/day +a0") of last & months, /aste !ater treatment +pro0ide 9ndustrial flo! dia"ram of the treatment 'omestic scheme , /aste !ater dischar"e ;uantity44444444444) m&/day <ocation4444444444444444

1&

Analysis of treated !aste !ater for parameters such as p=# B>'# C>'# ??# >1@ and any other as stipulated by the ?PCB/PCC + attach details, 1() Air Pollution Control a) $lo! dia"ram for emission control system +s, installed for each process unit# utilities etc) b) 'etails of facilities pro0ided control of fu"iti0e emission due to material handlin"# process# utilities etc) c) $uel consumption

Name of f e) a, b,

" a#t$t% *er Da%/Mo#th +

d)

?tac* emission monitorin" results

Sta!, atta!hed to+

Em$&&$o#& -for SPM. SO/. NO0 a#d Meta)& -)$,e P1 et!23 $# *art$! )ate& $# m4/Nm5

e)

Ambient air Auality

Am1$e#t Parameter& -SPM. SO/. NO0. a$r 6 a)$t% P1. a#% other 3 $# 74/ m5 )o!at$o#+

1-)

=aBardous !aste mana"ement a) /aste "eneration

: :

S2 No2

Name

Cate4or%

" a#t$t% - )a&t 5 %ear&3

b) 'etails on collection # treatment and transport : c) 'isposal +i, Please attach 'etails of the disposal facilities +ii, Please attach analysis report of characterisation of haBardous !aste "enerated +includin" leachate test if applicable,

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'etails of haBardous !astes proposed to be acAuired throu"h sale/ne"otiation/ contract or import as the case may be for use as ra! material) >ccupational safety and =ealth aspects Remar*s +i, !hether industry has pro0ided adeAuate pollution control system/ eAuipment to meet the standards of emission/effluent) +ii, !hether =/ collection and Treatment # ?tora"e and 'isposal $acility +T?'$, are operatin" satisfactorily) +iii,/hether conditions e%ists or li*ely to e%ists of the haBardous !aste bein" handled /processed of posin" immediate or delayed ad0erse impacts on the Dn0ironment) +i0, /hether conditions e%ists or is li*ely to e%ists of the !astes bein" handled / processed by any means capable of yieldin" another material e" # leachate !hich may possess ecoEto%icity) Any other 9nformation i, ii, iii, <ist of enclosures as per rule

1) Name ) ;uantity reAuired per year &) /aste listin" 1 No) in Anne% .999 +<ist A,/ 9C +<ist B, of Basel Con0ention +BC, () =aBard Characteristic as per Anne% 999 of BC Please pro0ide details of facilities pro0ided

Anne%

8es / No

8es / No

8es / No

8es / No

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S$4#at re + De&$4#at$o# + Date+2222222222222 P)a!e+222222222222