Download Application for Consent for Discharge/Continuation of Discharge

Sl. No..... I. To Member Secretary Tripura State Pollution Control Board Vigyan Bhawan, Gorkhabasti Agartala - 799 006, Tripura (West) From (Name & Address of the Applicant with Phone No.) Sub: Information about Industry I Factory I Unit 1. Name of the Industry/Factory/Unit : 2. Name of the Proprietor / Partner(s)/ : Managing Director/Manager 3. Address a) Industry/Factory/Unit Address : (With Telephone No. & Fax, if any) b) Office Address : (With Telephone No. & Fax, if any) , c)Address for correspondence : (With Telephone No. & Fax, if any) d) Residential Address of Proprietor/ : Partner(s) / Managing Director/ Manager(s) of the unit (With Telephone No. & Fax, if any) 4. Name, Designation & Correspondence : Address of the Contact Person (With Telephone No. & Fax, if any) 5. Name of the Owner of the Land/Premises : 6. a) Type of the Industry / Factory/Unit : (Indicate which type of Industry it is, e.g. Repairing & Servicing, Pathology, Saw Mill, Rice, Ice Factory etc.) b) Production Capacity : 7. Capital Investment a) Cost of Land : b) Cost of Construction of Building, : Shed (if rented, please indicate the Annual Rent) c)Cost of Plant & Machineries, : Instruments, Equipment & Furniture Total (a+b+c) 8. Category of the Industry/Factory/Unit Tiny Below Rs. 5 lakhs (Please tick) Small Rs. 5 lakhs-45 lakhs . Medium Rs. 45 lakhs-5 crores Large Above Rs. 5 crores 9. Consent Fees : (Please mention the Amount, DO/Banker's Cheque No., Date & Name of the drawing Bank) 10. Commissioning Date : (if not commissioned yet please mention . the proposed date of commissioning) 11. Total Area of the Unit : 12. City Survey No./Tauzi No : 13. Revenue Survey No. : 14. Daily Water Consumption in Kilolitre : a) Industrial use : b) Domestic use : (Including drinking purposes) : 15. Specification and details of the Generator : installed, if any. 16. A. Consent Status for Renewal a) First Certificate issued from the : Board (Please indicate the Certificate No., date of issue, consent fees deposited & expiry date). b) Successive Certificate(s) issued : i) from the Board (Please indicate the Certificate No., date of issues & ii) expiry date; separate sheet may please be attached, if necessary). iii) iv) v) vi) vii) viii) ix) c) Last Renewal Certificate issued : (Please indicate Certificate No., date of issue. consent fees deposited & expiry date). d) Arear of Consent Fees deposited in : this year, if any. B. a) Whether any modification, : Yes No alteration, extension, of any process in the unit has been done? (Please tick) b)If yes, please specify : (please attach separate sheet, if necessary) 17. Documents i) From I in triplicate duly filled up Submitted (Please tick wherever ii) From XIII in triplicate duly filled up applicable) iii) Consent fees Rs.--------------------- vide DD/Banker's Cheque No.------------------------- dated--------------- drawn on --------- ----------------------------------------------------------------------------- iv) Site Plan of the unit. vi) Project Report including details of Raw Materials and Fuel use, details of Process Description, Specifications and details of Plants and Machineries, Cost Analysis data. vii) Effluent Treatment Plant details, if any viii) Details of Air Pollution Control Measures, if any ix) Agreement copy of rent between the unit & the. landowner if the land/building is rented x) land and Building Valuation Certificate/Document x) Certificate from SDO/Competent Authority if the Agriculture land is/is being used for non Agricultural purposes. xi) Photocopies of City Survey No./ Tauzi No. & , Revenue No. xii) Photocopy of money receipt of Consent Form. xiii) No Objection Certificates from surrounding neighbours of the unit. xiv) Any other Information/Document (Please specify; Separate sheet may please be attached, if necessary) Date: Signature of the Applicant Place: Name of the Applicant Note: i) Please keep one photocopy of this form duly filled for future reference. Please keep photocopies of Form-I and Form-XIII duly filled for future reference. ii)" iii) Please apply for Consent to Operate/Renewal Certificate atleast one month in advance from the date of expiry of the last Consent Certificate