1[Form XIII
Application for consent for establishing or taking any steps for establishment of
Industry/operation/process/or any treatment/disposal system for discharge,
continuation of discharge under Sec. 25 or 26 Of the Water
(Prevention and Control Of Pollution) Act, 1974
(See rule 32)

From                                                                                                    Date…………
......................................
......................................
To
The Member-Secretary
Central Pollution Control Board,
Sir,
I/We hereby apply for Consent/Renewal of Consent under Sec. 25 or Sec. 26 of the Water Prevention and Control of Pollution Act, 1974 (6 of 1974) for establishing or taking any I/We hereby apply for Consent/Renewal of Consent under Sec. 25 or Sec. 26 of the steps for establishment of Industry/operation/process/or any treatment/disposal system to bring into use any new/altered outlet for discharge of sewage/trade effluent*/to continue to discharge*/sewage/trade effluent* from land/premises owned by
The other relevant details are as below --
1. Full name of the applicant……………………………..
2. Nationality of the applicant…………………………….
3. Status of the applicant
(a) Individual
(b) Proprietary concern
(c) Partnership firm (whether registered or unregistered)
(d) Joint family concern
(e) Private Limited Company
(f) Public Limited Company
(g) Government Company
(1) State Government
(2) Central Government
(3) Union Territory
(h) Foreign Company (If a foreign company/the details of registration incorporation, etc.)
(i) Any other Association or Body :
4. Name, Address and Telephone Nos. of the Applicant.
(the full list of individuals, partners, persons. Chairman (full time or part-time), Managing Directors, Managing Partners, (Directors (full time or part-time), other kinds of office-bearers are to be furnished with their period of tenure in the respective office with telephone Nos. and ,address).
5. Address of the Industry
(Survey No; Khasra No. Location as per the revenue record, Village, Firka, Tehsil, District, Police Station or SHO, jurisdiction of the First Class Magistrate).
6. Details of commissioning etc
(a) Appropriate date of the proposed commissioning of work.
(b) Expected date of production :
7. Total number of employees expected to be employed.
8. Details of licence, if any obtained under the provisions of Industrial Development (Regulation) Act, 1951, -
9. Name of the person authorised to sign this form
(The original authorisation except in the case of individual/proprietary concern is to be enclosed)
10.       (a) Attach the list of all raw materials and chemicals used per month.
(b) Licenced Annual Capacity of the Factory/Industry.
11. State daily quantity of water in kilolitres utilised and its source.
(domestic/industrial/process/bodies/boiler/cooling/others)
12.     (a) State the daily maximum quantity of effluents and mode of disposal (sewer or drains or river). Also attach analysis report of the effluents. Type of efficient quantity in kilograms, mode of disposal.
(i) Domestic
(ii) Industrial
(b) Quality of effluent currently being discharged or expected to be discharged.
(c) What monitoring arrangement is currently there or proposed.
13. State whether you have any treatment plant for industrial, domestic or combined effluents.
Yes/No
If yes, attach a description of the process of treatment in brief. Attach information on the quality of treated effluent vis-a-vis the standards.
14. State details of solid waters generated in the process or during waste treatment.

Description

Quality

Method of collection

Method of disposal

15. I/We further declare that the information furnished above is correct to the best of my/our knowledge.
16. I/We hereby submit that in case of change either of the point of discharge or the quantity of discharge of its quality, a fresh application for consent shall be made and until such consent is granted no change shall be made.
17. I/We hereby agree to submit to the Central Board an application for renewal of consent one month to advance of the date of expiry of the consented period for outlet/discharge if to be continued thereafter.
18. I/We undertakes to furnish any other information within one month of its being called by the Central Board.
19. I/We enclose herewith cash receipt no./bank draft no ... dated for Rs……….(Rupees………) in favour of the Central Pollution Control Board, New Delhi, as fees payable under Sec. 25 of the Act.
Yours faithfully,
Signature of the applicant
Note : *Strike out which is not relevant]
1. Subs. By G.S.R. 717 (E) dated 27th July, 1989 (w.e.f. 27th July, 1989).