Uttaranchal Environment Protection and Pollution Control Board, Dehradun Annexure to Application FORM 1-A(Water) Existing/New/Altered Outlet /Discharge Note : Any applicant knowingly giving incor ect information orsuppressing any information pertaining thereto shall be liable to punishedunderthe Act. While filling thisAnnexure,the applicant not concernedwithany ofthe item shall state "Not concerned"against the relevant one. 1. 1. Full Name ofthe Applicant with Address _____________________________ _____________________________ _____________________________ Tele No. _____________________ FaxNo. _____________________ 2. Full Name ofLand/Premises/Institute/ Factory/Industry/Local Body : With Address: _____________________________ _____________________________ Tele No. _____________________ FaxNo. _____________________ 3. Give revenue/City Survey Numberof Land/Premisesforwhichthe application ismade stating,district,tehsil,pargana andvillage Districy _____________________ Teshsil _____________________ Pargana _____________________ Village _____________________ City Survey No./Mauza House No. __________ Area in Hectares __________ Revenue Survey No. __________ Area in Hectares __________ 4. State monthandyearin whichthe land/ premises/institute/factory/industry was actually put into commission oris proposed to be put into commission orthe month andyearfrom whichthe local body is functioning _____________________________ _____________________________ _____________________________ _____________________________ _____________________________ _____________________________ 5. State the Civil/Military/Defence Industrial Estate etc. underwhose administrative jurisdiction the applicant'sland/premises issituated. Collectorate __________________ Municipality/Improvement Trust _____________________________ Village Panchayat ______________ Cantonment ______________ Defence ______________ Department ______________ ProhibitedArea ______________ 6. (a)State whetherthe land/premises institute/factory/industry hasbeen declaredasprohibited; (b)Ifyes,state the name ofthe authority andfurnisha certifiedcopy ofthe order underwhichthe area hasbeen declared asprohibitedarea Yes/No. 7. Isthe Industry/Factory forwhich application ismade closedon Sunday/Holiday. Yes/No. 8. State working season peryerforthe Industry/Factory Full Year From___________To______________ From___________To______________ From___________To______________ From___________To______________ ______________________Every Year 9. (a)Numberofworkerattending the facotry shift wise (b)Numberofworkersresiding in the premises ______________________________ ______________________________ 10. (ForLocal BodiesOnly): (a)Present Population (b)Population coveredunderregular sewer facilities (c)Population having septic tank/pit privy facilities (d)Population coveredby conservancy latrines _______________________________ _______________________________ _______________________________ _______________________________ 11. (ForIndustriesonly): (a)Give the list ofraw materialssuchas metals,alloys,chemicals,oilsfuels,etc. usedpermonthin Notice Metric Tons-Metal andAlloy Chemical Inorganic Dyes Organic Pesticides OilsandGrease Fuels: (a)Wood ...... (b)Coal ...... (c)Oil ...... (d)Gases ...... (e)Others...... (B)Give the list ofname ofProduct Sl. No. andby -productsmanufacturedper monthin (MT) Name/Weight Name/Weight Name/Weight Name/Weight Name/Weight Name/Weight Name/Weight Name/Weight Name/Weight (C)Give the list ofPossible Intermediate products Name ofProduct Quantity in M.T. Permonth 12. State daily quantity ofwaterin litres Utilised. Uses___________________________ (Domestic/Industrial/Agricultural/Other 13. (A)State the hourly maximum anddaily quantity ofef luentsarising from land/ premisesforwhichthe application ismade : (a) (b) (c) (d) (e) Domestic Industrial Agricultural Other Total quantity ofef luent (B)State how measurement ofrate and quantity are car iedout : 14. State whetherstorm waterdrainsare kept separate from Industrial /Domestic ef luents? Yes/No. 15. (a)Isdomestic ef luent allowedto get (b)Ifyes,state ratio : Yes/No Domestic/Industrial 16. (a)Describe ifany treatment for industrial ordomestic ef luent orone for combinedef luent ismade. Ifyes, state the processoftreatment in brief (separately) Yes/No Yes/No (b)Isthe quality ofef luent emitting eitherwithout oraftertreatment approvedby any authority ? (c)Ifapproved,furnishthe authority (two certifiedcopiesto be sent). 17. Isthere any provision fordisposal of: Already Made Proposedto be Made (a)Domestic ef luent in public underground sewer Yes/No Yes/No (b)Industrial ef luent in public underground sewer. Yes/No Yes/No (c)Give the name ofpublic authority owning the sewer. Yes/No Yes/No 18. Isthere any provision fordisposal of: Already Made Proposedto be Made (a)Domestic ef luent overlandfor ir igation Yes/No Yes/No (b)Industrial ef luent overlandfor ir igation Yes/No Yes/No Domestic ef luent in the underground strata Yes/No Yes/No (d)State the area oflandusedfor: A above in hectares (e)State the area oflandusedfor: B above in hectares 19. Give the quantitative disposal ofef luent in litresprovidedforthe placesmentioned below: Domestic/ Industrial Mixed (a)Stream/River (b)On landforir igation (c)On landforpercolation (d)Lake/Pond 20. Isthere any provision forequalising or holding lagoonsfortanksto store the ef luentsduring unfavourable steam conditions: (a)Domestic ef luent (b)Industrial ef luent (c)Combinedef luent Already Made Proposedto be made 21. Issuf icient landavailable/can be made available ?In case pumping ef luent;onlandshave to be considered 22. (a)Give detailsofcomposition of Domestic/ Industrial/combinedef luent in respect of the following : Ef luent before treatment Ef luent aftertreatment EBT EAT At Max. Dis At. Min. Dis At Ave. Dis At Max. Dis At. Min. Dis At Ave. Dis (i)(A)pH (ii)(B)Colour-Units Hazen unit (iii)Temperature 0C (iv)SuspendedSolids: (a)Total mg/L (b)FixMg/L (c)Volatile mg/L (v)DissolvedSolids: (a)Total mg/l (b)FixMg/L (c)Volatile mg/L (vi)Total volatile solids mg/L (vii)Ammonical Nitrogen (mg/L)N (ix)DissolvedOxygen mg/L (x)B.O.D. 5days200C mg/L (xi)C.O.D. mg/L (xii)Oil andGrease mg/L (xiii)Chloride mg/Las (Cl) (xiv)Phosphates(P) mg/L (xv)Phenolic Compounds mg/L(asPhenol) (xvi)Cyanides(asCN) mg./L (xvii)Sulphate (asSo2) mg/L (xviii)Sulhides(asS4) mg/L (xix)Insecticidesmg/L (xx)Total aresidual Chlorine (asCl2)mg/L (xxi)Flouride (asF)mg/L (xxii)Boron (asB)mg/L (xxiii)Aresenic (asAs)mg/L (xxiv)Barium (asBa (mg/L) (xxv)Percent Sodium (xxvi)Cadmium (asCd)mg/L (xxvii)Copper(asCu)mg/L (xxviii)Lead(as(Pb)mg/L (xxix)Chromium -(a)asCr. (mg.L);(b)Valency as(Cr) mg/L (xxx)Mercury (asHg.)mg/L (xxxi)Nickel (asNi)mg/L (xxxii)Selenium (asS)mg/L (xxxiii)Silver(asAg)mg/L (xxxiv)Zinc (asZn)mg/L (xxxv)Any othermetalsmg/L (xxxvi)Carbon Chloronform Extracts (xxxvii)Pesticides(mg/L) (xxxviii)Coliform organismsMPN per (100mg)(monthly average) (xxxix)Bioassay forToxic Constituents. TI50 (96hours) Note: (1)Furnisha copy ofthe analysisreport ofrepresentative samplescar iedout by a competent laboratory. (2)Methodsofdetermination asapprovedby the Boardwill be followedfor determination ofabove mentionedparameters. z (B)Isthe ef luent toxic ? Yes/No (C)State ifthe industrial ef luent ishaving Yes/No (a)Unpleasant smell (b)Ir itating and/orharmful (c)Cor osive (d)Withcolour (D)Isthere any hidden change oftemperature exceeding 100Cat any time. Yes/No Yes/No Yes/No Yes/No Yes/No 23(A)Are facilitiesavailabe withthe applicant forrequirement arising out ofthe following testsofthe waste waters: Existing Proposed (a)Physical Yes/No Yes/No (b)Chemical Yes/No Yes/No (c)Bacteriological Yes/No Yes/No (d)Toxicological Yes/No Yes/No (e)Ifyes,give detailsofequipments. 24. Hasthe land/premisesetc. forwhichapplication ismade open ? Highly polluting material_______________ Tox/Organic/Inorganic/Microbiological (A)Cooling Tanks (B)Mixing Tanks (C)Mixing Ponds (D)Re-circulation wells 25. State detailsforsolidwastes: Describe Quantity MethodofDisposal A Seasonal Waste BSpillage CRejectedmaterials 26. Total Investment ofPlant Accompanimentsifany :-Signature___________________ Name andaddressofthe applicant on behalfof _______________________ Name andAddressofthe Firm__________________________________ on behalfofwhichapplication is made________________________________
