FORM II

(See rule 10)

[APPLICATION FOR AUTHORISATION
OR
RENEWAL OF AUTHORIZATION
(To be submitted BY Occupier of Health Care Facility or Common Bio Medical waste
treatment facility)

To

The Prescribed Authority

(Name of the State Govt/UT Administration)
Address.
1. Particulars of Applicant

(i) Name of the Applicant ANUSURI SRINIVASULU

(In block letters & in full)
(ii) Name of the health care facility (HCF) or common bio medical waste facility
(CBMWTF) : SREELATHA HOSPITALS
(iii) Address for Correspondence:

(iv) Tele No.

(V) Email: (Vi) Website Address:

2. Activity for which authorisation is sought:

(i) Activity
(ii) Generation, Segregation
(iii) Collection
(v) Storage

1. Application for Fresh or Renewal of Authorization (Please tick whatever is

applicable):
(i) Applied for CTO/CTE Yes/No
(ii) In case of renewal previous authorization number and date.
(iii) Status of consents
(a) Under the water (Prevention and Control Of Pollution)Act,1974
__________________________________________________
 (b) Under the Air (prevention and Control of Pollution)Act,1981:
___________________________________________________
(I) Address of the care facility (HCF) or common Bio-Medical waste treatment
facility (CBWTF) EVB TECHNOLOGIES
(ii) GPS coordinates of health care facility (HCF) or common bio-medical
waste treatment facility (CWWTF)
2. Details of health care facility (HCF) or common bio-medical waste treatment facility
(CBWTF)
(I) Number of beds of HCF: 100
(II) Number of patients treated per month by HCF:
(III) Number health care facilities covered by CBMWTF: __________
(IV) No of beds covered by CBMWTF:___________
(V) Installed treatment and disposal waste treated or disposed by
CBMWTF:---------------- kg/day
(VI) Quantity of biomedical waste treated or disposed by CBMWTF:_______
kg/day
(VII) Area or distance covered by CBMWTF : _____________________
(pl. Attached Map a map with GPS locations of CBMWTF and area of coverage)
(Viii) Quantity of Biomedical waste handled treated or disposed:
Category Type of waste Quantity Generated Method of Treatment
or collected .kg/day and Disposal (Refer
Schedule-I)
(2) (3) (4)
Yellow (a) Human Anatomical waste:
(b) Animal Anatomical waste:
(c) Solid waste
(d) Expired or Discarded
Medicines
(f) Chemical Solid waste
(e) Chemical Solid Waste
(f) Chemical Liquid Waste
(g) Discarded linen,
mattresses bedding
contaminated with blood or
body fluid.
h) Microbiology
Biotechnology and other
clinical laboratory waste:
Red Contaminated waste
(Recyclable)
White Waste sharps including
(Translucent) metals
Blue Glassware:
Metallic Body implants

6. Brief description of arrangements for handling of biomedical waste (attached

details)

(I) Mode of transportation (if any) of bio-medical waste:

(ii) Details of treatment equipment (please give details such as the number,
type & capacity of each unit)
No of units Capacity of each unit

Incinerators:
Plasma Pyrolysis:
Autoclaves:
Microwave:
Hydroclave
Shredder:
Needle tip cutter or destroyer
Sharps encapsulation or concrete pit:
Deep burial pits:
Chemicals disinfection:
Any other treatment equipment:

7. Contingency plan of common bio-medical waste treatment facility

(CBMWTF) (ATTACHED DOCUMENTS): EVB TECHNOLOGIES

8. Details of directions or notices or legal action if any during the period of

earlier authorization.

9. Declaration.

I do here by declare that the statements made and information given above are
true to the best knowledge and belief and that I have not concealed any information.

I do also hereby under take 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

3.

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

Enclosures Required: CBMWTF Certificates/ Bill (M/s. EVB Technologies)

Previous BMW authorization order copy.
DM& HO Registration certification copy.
 FORM III

(see rule 10)

AUTHORISATION

(Authorization for operating a facility for generation, collection, reception, treatment,

storage, transport and disposal of biomedical waste).

1. File number of authorization and date of issue _____________________

2. M/s. ____________________________ an occupier or operator of the facility

located at ________________________________ is here by granted an
authorization for :

Activity
Generation, segregation
Collection,
Storage
Packing
Reception
Transportation
Treatment or processing or conversion recycling
Disposal or destruction use offering for sale, transfer any other form of handling

3. M/s. ___________________________________________ is here by authorized

for handling of biomedical waste as per the capacity given below.
(i) Number of beds of HCF:50
(ii) Number of healthcare facilities covered by CBMEWTF:
(iii) Installed treatment and disposal capacity: ___________________ Kg per
day.
(iv) Area distance covered by CBMWTF:________________
(v) Quantity of Biomedical waste handled, treated or disposal.

Type of waste category Quantity permitted for handling

Yellow

Red

White (Translucent)

Blue

4. This authorization shall be in force a period of -----------------10----------- years

from the date of issue.

5. This authorization is subject to the conditions stated below and to such other
conditions as may be specified in the rules for the time being in force the
Environment (Protection)Act,1986

Date............................... Signature ............................

Place.............................. Designation............................
TERMS AND CONDITIONS OF AUTHORISATION*

1. The authorization shall comply with the provisions of the Environment

(protection) Act, 1986 and the rules made there under.
2. The authorization or its renewals shall be produced for inspection at the request
of an officer authorized by the prescribed authority.
3. The person authorized shall not rent, lend, sell, transfer or otherwise transport
the bio medical waste without obtaining prior permission of the prescribed
authority.
4. Any unauthorized change in personal, equipment or working conditions as
mentioned in the application by the person authorized shall constitute a breach
of his authorization.
5. It is duty of the authorized person to take prior permission of the prescribed
authority to close down the facility and such other terms and conditions may be
stipulated by the prescribed authority.
 INFORMATION TO BE SUBMITTED ALONG WITH BMW APPLICATION FORM-I

Name of the Hospital

Door No.

Street Name

Nearest Land Mark

Name of the city /town/village

Name of the Doctors 1.
2.
3.
Phone Numbers
Date of Establishment
Specialization
Govt/Private/Public/sector private
Number of beds 100
Whether Blood Bank/Lab
attached
Fee to be payable. d.d enclosed
st
1 time (Fresh) @ Rs.100 per bed
per annum and Renewal @ Rs.50
per bed per annum.
Quantity of BMW waste
generation
Member of M/s. EVB yes
technologies,
If yes details of membership Copy enclosed
Hospital total area with built-up
Surroundings of Hospital
East:
North:
West:
South:
Whether the HCE is having valid Authorization No.
authorization from A.P. Pollution Valid up to
Control Board if yes details of
authorization copy.
Whether the HCE is having Authorization No.
registration with DM&HO if yes Valid up to
details of registration copy.