The existing FORM I and FORM I-A appended to the said rules, shall be subslituted,bythe following new FORM I, namely:- ' 'FORM I Application for consent to Establish/consent to operate under section 2l of the Air (Prevention and Control of Pollution) Act, l98l From:- To, Member Secretary/ Regional Offrcer, Rajasthan State Pollution Control Board, Sir, I/We hereby apply for obtaining 'Consent, in Form No. I under section 2l of the Air (Prevention and Control of Pollution) Act, l98l (No. 14 of 1981), for establishing an industrial planV operatior/ process/ activity or for Consent to Operate any industrial plant owned by ................ (Name of Director/ proprietor/ partner etc.)
Part I: General Information A. Details of Industry/ Activityl Service/ Operation/ Process:- I 2 3 a. Name of Industry/ Activity/ Service/ Operatior/ Frocess b. Name and Designation of the Applicant c. Correspondence Address Plot No./ Khasra No.
Telephone No. (including Plot No./ Khasra No.
Street/ LocalitY/ CitY fet"phone No. (including Land classification 1 2 3
(b) Commercial, or
(c) Agricplture, or
(d) Residential, or
(e) Other than above g. Whether covered under Aravalli Notification h. Whether requiring authorization under the rules dealing with Hazardous Waste notified under Environment (Protection) Act, 1986 and quantity of used/ waste oil i s > 5 K L I Whether covered under EIA Notification. 2006 I J Gross Built up Area k. Consent is applied for (Entire Industry/ ActivitY/ Service/ Operation/ Process or Part thereof- Please specif) L m.
Category of lndustry/ Activity/ Service/ Operation/ Process Redi Orange/ Green Scale otlndustry/ ActivitYl Service/ Operation/ Process t a.g.ltr{.aluny Small/Tiny/ Other n. Status of IndustrY/ ActivitY/ Service/ OperatiorV Process Proposed/ Under Construction/ OperationaV Non-OPerational o. Total Capital Investment (without dePreciation) in Industryi ActivitY/ Servicel Operation/ Process (as Per Project RePorti CA Certificate) for which consent is aPPlied (Rs. in lacs) zz-)(6) trwqrq{rq-{r',@ I 2 3 p. Date of Commissioning q.
-Totil number of emPloYees (including contractual workers) in the Industry/ Activity/ Service/ Operatiott/ Process (maximum) r. Total number of residents in the colony; if anY within the premises of the establishment s.
t.
Installed CapacitY of the Industry/ Acti vitY/ Service/ Operatior/ Process Name Quantity (with unrt) No. of working daYs in a year u. No. of shifts Per daY v. Electric connection number and name B. Surrounding Details:- eam/ River/ Pondr Dam/ anY other water bodY tnOustriut area (SPecifY) nny tnajot indusfrY (SPecifY) Which of the bil"*i"g f*t"*t .-t.t within I km of the site Htman S"ttt.*ttt (Village/ City/ Town) Part IIt Information related to Industry/ Activity/ Service/ Operation/ Process
(a) Type of Industry/ Activity/ Servicei Operation/'Frocess:
(g) Manufacturing
(h) Healthcare ' (i) Hospitality C) Project
(k) Mine 0) Any Other (Please Specify)
(b) Raw Material Details:
In Pollution Conhol Measure Nature (Solid, Liquid, Gas) Storage Capacity (With Unit)
(c) Product/ By Product/ Service/Activity details Quantity/ Capacity (With Unit) Storage Capacity
(d) Electric Energy Requirement (Kilo Watt) ?7_(8) qtiirceriq qrur-Er, tr$ z, 2o1s
(e) Water Requirement (Kilo liter per Day) Total Water Requirement Fresh Water Component
3. I Recycle Water Component
(f) Water Consumption Details (Kilo liter per Day) Fart III: Information related to Effluent Generation, Treatment and Disposal
(a) Effluent Generation & Disposal Details S.
No.
Source of Waten Boiler/ Cooling Domestic Industrial Proccss Any 'other use Total Consumption Flow mesrritrg dqicc Surface water
2. Ground 14'ater 3 RIICO/ PHED supply 4 Recycled water 5 Any Other (Please speciff) Total S.
No.
Type of Effluent (Trade/ Domestic) Quantity of Effluent Generated (KLD) Recycled in the Process/ Activity (KLD) Disposed/ .Discharged (KLD) Il{ode of Disposal I a 3 4 f, 6 2
(b)Number of discharge outlet (s)
(c) Mode of treatment and disposal Part IV: Information related to Air Pollution and Control Systems
(e) Air Emission Details Mode Yes/ No Capacity Mode of conveyance of effl uenl Connected to CETP/ Common STP Yes/ No Open drain/Closed Conduit/Tankers/Other (Please specily) Having own ETP Yes/ No Open drainiClosed Conduit/Tankers/Other (Please specily) Having own STP Yes/ No Open drain/Closed Conduir/TankersiOther (Please specily)
(d) Type of treatment system installed S. No.
I Type (Sewage Treatment Planti Emuent Treatment Plant) Unit Operations & Process installed Capacity ofthe Treatment System I
2.
J .
Itrfrr$rtctural motitoring (Yes/ No/ Not r€quircd) 2tJl0) qlur,tqrq qruT-q-{, q$ z', zors qrq + (9 Part V: Information related to Solid Waste:
T Wrt.tt*t *t"*d I under the rules I dealing with --1-'-_ -i ---f- . t l . L _ _ L - _ _ _ - | - , , - - , - - ) Fu.lVf t Information related to Consent Fee Deposition s. NuT-tll nafbloer Date No./ ECS Transaction No./ Token no./ Challan No.
stack emission nro[itoring (Yes/ No/ Not required) of Strck (itr meter) Source/ Process Quantity Mode of I storage Mode of disposal t - - - - I Hazarclous Waste notif ied under r Envi ronment i (Protection) Actn 1986 a. I/ We, hereby declare that the informatioir furnished above is correct to the best my/ our knowledge b. I/We, hereby submit that in case of change in either of the ili"; ;i.;lssion or characteristic of ernission or change in itack o, process of operalion, an application for consent shall ;;"d."'"ttd untit suctr consent is granted no change shall be made.
I/We, understand the State Board and its official authorized in il;H;li;f t[e stat. Board can make necessary changes/ ilfi*tlo;in the data provided by me/ us while deciding the ;;;il,t"" ln the basis of th" infottation provided by me/ us' Bank Name/ e-Mitra/ CSC .Trq.4 (rr) Wq$ z. zors zz (tt) Signature Name Designation Seal Note:
I. consent application must be accompanied with the fees as specified in the notifications issued by the State Government time to time.
II. consent fee shall be paid through Bank Draft payable in fbvour of the Mernber Secretary, Rajasthan State pollution control Board or through ECS or through e-Mitra/ csc or Bank challan or any other facility as per orders issued by the State Board time to time.
III. Documents as per check list as speciliecl by the State Board shall be submitted along with the application.
IV. All documents including consent application form submitted to the State Board shall be signed/ attested by the proprietor/ authorized signatory along with seal. " Date:- Place