The existing FORM XIII and XIII A appended to.the said rules, shall be substituted by the following new FORM XIII, namely:- ,,FORM XIII Application for Consent to Establish/ Consent to Operate under section 25126 of the Water (Prevention and Control of Pollution) Act, 1974 From:- . w"r,!:.r:..lj"$i.......
To, Member Secretary/ Regional Officer, Rajasthan State Pollution Conffol Board, Sir, I/ We hereby apPlY for obtaining 6nsepti" Fo.m XIn, ilaa;Att"n 25l 26 of the Water (Prevention and Control of Pollution) Act, 1974 (No. 6 of 1974) for establishing an industry/ operation/ process/ activity/ service or any treatment and disposal system or for Consent to Operate for bringing into use or to continue to use any new/ altered outlet or for discharge of sewage/ trade effluent or to continue to discharge sewage/ trade effluent or discharge of sewage/ trade effluent on land/ premises owned by (Name of Director/ proprietor/ partner etc.)
Part I: General- Information ttsrgen"T tg-rl-T. tr$ z. zOrs A. Details of Industry/ Activity/ Service/ Operation/ process:- Name and Designation ofthe Correspondence Addiess eZJl8) rrqqern qm-.rt, q{ z, zors qm + {rr) MobileNo.
Fax No.
e. Plot Area/ Mining Lease Area f. Lsrd chssiftcation
(a) Irdustrial or
(b) Commercial, or
(c) Agriculture, or
(d) Residential, or
(e) Otherthan 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 ofused/ waste o i l i s > 5 K L Whether covered under EIA Notification, 2006 J. Gross Built up Area k Consent is applied for (Entire Industy/ Activity/ Service./ Operatior/ Process or Part thereofplease speciff) t. Category of Industry/ Activity/ Service/ Operation/ Process Red/ Orange/ Green m. Scale of Industry/ Activity/ Service/ Operation/ Process Largel Medium/ Small/ Tiny/ Other n. status oI mdustry/ Acttvlty/ Service/ Operatior/ Proc€ss Proposed/ Under Construction/ OperationaU Non-Operational o. Total Capital Investrnent (without depreciation) in Industry/ Activity/ Service/ Operatior/ Process (as per Project ReporV CA Certificate) for which consent is applied (Rs.
in lacs) totat numbei oGmptoyd (mcludlng contracfual yolkTr) in the Indusrry/ Activit)/ Service/ Operation/ process (maximum) Total number ofGidentJE fte colony; if any within the premises of *," establishment fnstalled Capacifi of thmdustry/ Activity / Service/ Operation/ process No. of working days in a No. of shiftiper?iy Which of tne ,. of the site Humanse@ Forest Sanct River/ Pond/ Dam/ any other water bodv Industrial a.ii@peci$ Any major inaustry lSpeiiryy Part rr: rnformarion rerated to rndustry/ Activity/ Service/ operation/Process
(a) Type of Industry/ A ctivity/service/ Operation/ process:
(a) ManufaCturing
(b) Healthcare
(c) Hospitatity - r Z, ZOIS gfq + (rf) zz (zo) qrq*effi RTq-qr' .rE
(d) Project
(e) Mine (0 AnY Other (Please SPeciff) O) Raw MaterialDtgttt Electric Energy Requirement (Kilo Watt) Water Requirement (Kilo liter per Day)
(c), Prqduct/ By Product/ Service/Activity details h Poltution Control Measure Totat Water Requirement Fresh Water ComPonent (0 Water ilEaitJ(rito titer Flow measuring device Domestic -Industrial ' 'Pio.it. ' Any other uses.
No.
Source of Water Boiler/ Cooling rl Part III: Information rerated to Eflruent Generation, Treatment and Disposal
(e) Effluent Generation & Disposal Details I ) 3 4 5 6 7 8Surfap!
water I 2 3 4 6 7 8
2. Ground water 3 . RIICO/ PHED supply
4. Recycled water 5 . Any Other@leas e speci$) 6- Total
(f) Number of discharge outlet (sf
(g) Mode of treatment and disposal Mode of conveyancC otitflilnl Open drain/Closed eonduit/t (Please speci$) Open drain/-loGd Condui 21p2) nq*rn trq-qt, € z, zots qrr + fT)
(h) Type of treatment system installed Fa* IV: Information related to Air Pollution and Control Systems
(a) Air Emission Details I 2 3 4 Having own STP YeVNo Open drafu/Closed ConduiUTankeryOthet (Please speci$) S. No. Type (Sewagc Treatmcnt PlanV Efituent Treetmcnt Plant) Unit Oper|tions & Process instrlled Capacity ofthe Tr€rtment System
2.
, .
A P|@r Strcls S. No, Sarqk rttrchcd to p|!€t St|ck bcighl freo SnuEd lcvcl (i[ mctcr) Irchilr of Air Pollutiotr Cualol Ms!H Prcbrblc polluamts hfrutructunl moDitortog frcilitY (Yc!r'No/Not Equircd) B f,ltr. sdd atrckr S. Nc Strck t.tr3hcd to Plrot Fucl Rrt d fucl ouumptaoB (lU br, KS/hr) $trck hcight fnm gnund ldcl (in mcatr) Dtuol Ail ?olludoD Contml pollutrrtt hrrutructunl monitoring frcility . (Yd/No/Not c Furitivc mhrion S. No Sourcc Pnbrblc polhhrtt Dctrilr ofAir Pollution Cootrel Mdtrro D Itctrilt ofD. G. Sctr S. No Rrti[g (KVA/KW) St tI' of -Asstic ilclolurc Hcigha of Strcf, (in mcts) hfnrtrocturc frcilitiB for ilrck c[i$bn mtitoring (YcdNo/Not rcquind) Abov. rool I Abovc Ground ldcl {rq-EITT{T 4 Part V: Information related to Solid Waste:
Part VI: Information related to Consent' Fee Deposition ct to the best my/ our knowledge' I/We, hereby submit that in case of change' either of the point of characteristic of dischargeorthequantilT"oi"n'"[ilTTi*,:rfiif, tJ|j"l}rfi:
"";*"iln-"t be made and until.such consent rs I made.
l/tlVe, understand the State Board and its oficialauthorized in this behalfby the State Board can make "J;';;;et'/ 'noaintttion in the data provided by me/ us while deciding 'ni"#L"ii"" "n the basis of the information provided bv me/ us.
Date:.
Place Sigoature Name Designation Seal fr[E-hether covered under the rules dealingwith Ilazsrdous Waste ' notlfied under Environment (Protection) Act' r9E6 Source/ ProcesS' Eil[t'tiilJe'vtiral ,t -t, 2?-J24) rrq{err{ qtq-Td. T$ t, 201 Note:
(D Consent application must be accompanied with the fees as specified in the noti{ications issued by the State Govemment time to time.
(i!) Consent fee shall be paid through lank Draft payable in favour.of the Member Secretary, Rajasthan State Pollution Control Board or through ECS or throughv v v r v l u | J , e-Mifra/ CSC or Bank Challan or any other facility as per orders issued by the .dc$tateFoard time to time.
(iii) Documents as per check list as specified by the State Board shall be submitted lilong with the application
(iv) All documents including consent application forrn submitted to the State Board l shall be signed/ attested by the proprietor/ authorized signatory along with seal. l