Shilpa Sathi COMMON APPLICATION FORM FOR SETTING UP AN INDUSTRY IN WEST BENGAL

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1 COMMON APPLICATION FORM FOR SETTING UP AN INDUSTRY IN WEST BENGAL SWS IDENTIFICATION NUMBER General Information [Please see Instructions before filling up the Application] 1. of the Applicant: Residential Address 2. Sex: Male Female 3. Father s / Husband s : 4. Trade / of the factory: 5. Address of the Principal place of business/ Registered Office: Municipal / Local body Ward No. Mouza J. L No. Telephone Number Fax No.(with STD code) 6. Occupancy Status : (Refer to Instruction sheet ) 7. Status of the business : (Refer to Instruction sheet ) 8. Contact Numbers of one contact person: Status of Contact Person 9. Address and Telephone number of Factory in West Bengal: Address: Mouza Dag No.& J.L. No. P.O. District Telephone No. (with STD Code) P.S Page 1 of 7

2 10. Address of Branch Office within West Bengal. 11. Nature of Business: (Refer to Instruction sheet ) 12. Item(s) of Manufacture a) Item of manufacture b) Item code (NIC Code) c) Proposed annual capacity 13. Number of Registration Certificate issued by Registrar of Companies, West Bengal: 14. PAN/TAN Number of the firm under the Income Tax Act, 1961 (if any): 15. ECC Number under the Central Excise and Tariff Act, 1985 (if any): 16. Land Requirement (In Square Meters : smt = 1 hectre ; 4000 smt = 1 acre) a) Total area of land in possession b) Area required for Project i) Main factory building ii) Storage iii) Administrative building iv) Others 17. Estimated project cost (Rs. Lakh) a) Land b) Building & workshops c) Plant & Machinery d) Others TOTAL 18. Means of Finance (Rs. Lakh) Promoters Equity Strategic Investor Borrowing 19. Foreign Investment (Rs. Lakh) Equity In other form 20. of FI/Bank which has approved Project for Financing: of Bank Branch 21. Employment : Direct Indirect Skilled Page 2 of 7 Unskilled

3 Total Number of employee a) In the factory b) In the Shop/ Establishment TOTAL 22. Requirement of infrastructure At commencement of production stage a) Water (litres/day) b) Power (KVA) At full capacity production stage Source 23. Expected date of commencement of construction: 24. Expected date of commencement of production: 25. Appendix A : [FOR TRADE LICENSE/POWER SUPPLY/FACTORY LICENSE/SHOPS & ESTABLISHMENT] Particulars Required for Trade License Whether Air-conditioned: Yes No Monthly Rent (Rs) (if applicable): The H.P. of motors in case of workshop/factory: Up to 10 H.P Water Supply ICI Consumer? Yes No If Yes, please mention the Consumer No. I.T. Industry Certificate No. 26. Particulars for Power Supply Above 10 H.P. of Power Supply Agency CESC WBSEDCL DVC (Please Tick) DPSC DPL Voltage of Power Supply Required 6KV 6.6KV 11KV (Please Tick) 33KV 132KV 220KV Total power supply requirement in KVA/HP in phases with time schedule Phase Requirement in KVA Requirement in HP 1 st Year 2 nd Year 3 rd year 4 th Year 5 th Year Scheme of set-up of the new unit: Capacity Capacity Capacity of captive sets Planned Capacity of Machinery and Maximum Demand for first five years 1 st Year 2 nd Year Aggregate capacity of machinery in Horse Power Proposed to be installed Page 3 of 7 Maximum Demand In KVA

4 3 rd Year 4 th Year 5 th Year Proposed working hours and load maintained Period of shifts Summer Winter Stage of construction Stage of construction Factory Office Probable date when the installation will be ready to receive power Quantum of power required, if any, during construction period Load Maintained KVA From To 27. Additional Information Required by Factories Department Nature of manufacturing process Carried on In last 12 months To be carried on in the next 12 months Maximum number of workers (including staff, officers, contract labours etc.) likely to be employed in the factory on any day during the next twelve months and on any day during the previous twelve month Adult (over 18 years of age) Adolescent (over 15 but under 18 years of age) Children (over 14 but under 15 years of age) Total (including male & female) Male (in the preceding 12 months) Male in the next 12 month Female in the preceding 12 months Female in the next 12 months Details of Manager Age Father s / Husband s Present Address P.S. of present Permanent Address P.S. of permanent Page 4 of 7

5 Details of Directors / Partner / Proprietor (Designated as Occupier under 2(n) of the Factories Act, 1948) (For other Directors/ Partner use separate Sheet, if necessary). Age Father s / Husband s Present Address P.S. of present Permanent Address P.S. of permanent In case of a factory constructed or extended or taken into use after the date of commencement of the Rules--- Approval of plants by State Government/ Chief Inspector Approval of the arrangements, if any, for disposal of trade waste and effluents Reference Number Date (Signature of the Manager) (Signature of the Occupier) 28. Additional Information For Shops & Establishment Registration Category of establishment Weekly Closing Day 29. Appendix B : APPLICATION FOR CONSENT TO ESTABLISH (WEST BENGAL POLLUTION CONTROL BOARD) 1. Category of the Industry: (a) Green (b) Orange (c) Red (Please strike out whichever is not applicable) 2. Size of the Industry: (Please strike out whichever is not applicable) (a) Small (b) Medium (c) Large 3. Gross estimated capital investment: Rs. (Land, building, plant and machinery) 4. Attach the list of raw materials and fuel with estimated monthly consumption Sl No. Item (Raw material and fuel) Quantity per month 5. Attach the list of products and byproducts Sl No. Item (Raw material and fuel) Quantity per month Information on Water Consumption and Water Pollution Control 6. Water Consumption Type Supply source (Strike out whichever is not applicable) Quantity (m 3 /day) Page 5 of 7

6 Industrial Domestic (drinking/canteen/bathing) Others (please specify) Municipal/ Well/ Tube well/ Canal/ River/ Others (please specify) Municipal/ Well/ Tube well/ Canal/ River/ Others (please specify) Municipal/ Well/ Tube well/ Canal/ River/ Others (please specify) 7. Effluents/ Liquid Wastes Type Quantity (m 3 /day) Place of discharge Industrial Domestic 8. Information on characteristics of Effluents/ Liquid Wastes (not necessary for the Green Category) (attach additional sheets if necessary) PHYSICAL CHEMICAL/BIOLOGICAL Parameters Expected Value Parameters Expected Value Temperature ( 0 C) BOD (mg/l) ph COD (mg/l) Colour Heavy Metal (mg/l) Turbidity(JTU) Toxic elements (mg/l) Odour Total Solids (mg/l) Total Suspended Solids (mg/l) Oil and Grease (mg/l) 9. Proposed facilities for effluents/ liquid waste treatment (Industrial/Domestic) (not necessary for the Green Category) Please attach the details on a separate sheet Information on Possible Sources of Air and Noise Pollution and their Control (not applicable for the green category) 10. Emission Sources Please attach details of air pollution sources and control measures (use additional sheets, if necessary) Sources of Emission Process Blast/ Cupola/ Rotary/ Revervatory/ Induction/ Arc/other Furnaces Heater/ Thermic Fluid Heater Kiln Boiler Others No. of Units Capacity of each unit Fuel (Type & Quantity) 11. Sources of Noise Pollution Please attach details of Sources and Pollution Control Measures Page 6 of 7 Proposed Air Pollution Control Systems 12. Information on Diesel Generator Sets (for all three categories) No of DG Sets Capacity of each Height of Stack above DG Room Height of DG Room Stack Height (from Ground Level) Noise Pollution Control Measures Acoustic enclosure/ Exhaust acoustic treatment Muffler of DG Room

7 13. Hazardous Materials/ Chemicals for the Process and Description Hazardous Chemicals to be handled under Manufacture, Storage and import of Hazardous Chemicals Rules, 1989 (MSIHC) Attach separate sheet if necessary Qty/ day Maximum quantity of Hazardous Chemicals to be stored at a time under Manufacture, Storage and import of Hazardous Chemicals Rules, 1989 (MSIHC) Attach separate sheet if necessary Please attach copies of MSDS 14. Solid and Non-hazardous Waste Generation (for Orange and Red Categories only) Generated from Qty/day Composition Treatment and disposal method proposed Process ETP sludge Air Pollution control devices Scrap Others, if any 15. Solid and Hazardous Waste Generation (for Orange and Red Categories only) Generated from Qty/day Composition Treatment and disposal method proposed Process ETP sludge Air Pollution control devices Scrap Others, if any 16. Pollution Control Management Implementation of Environmental Management Plan including organizational setup Pollution Control Equipment and running cost Expenditure incurred for setting up and running monitoring system 17. Please indicate whether the industry attracts the provisions as laid down in the EIA Notification S.O dated 14/09/2006 of the Ministry of Environment and Forests, Govt. of India and amendments thereof Yes No Date (Signature of the Applicant) Page 7 of 7

TAMIL NADU POLLUTION CONTROL BOARD FORM I

TAMIL NADU POLLUTION CONTROL BOARD FORM I Application for consent under Section 21 of the Air (Prevention and Control of Pollution) Act, 1981 as amended (Central Act 14 of 1981) (See Rule 7 of the Tamilnadu