FORM

Common Application for Consent under

Water (Prevention and Control of Pollution) Act, 1974,
Air (Prevention and Control of Pollution) Act, 1981) and Authorization under
Hazardous Wastes (Management and Handling ) Rules, 1989 as amended.

No...........
Accompanying form in triplicate to be submitted by
the applicant. One copy may be retained applicant.
Explanatory note for filling in application form for
Consent/Authorization

1. Any applicant knowingly giving incorrect information or suppressing any Information

pertaining to any of the items of the application shall be liable for punishment as per
provisions under the Relevant Act.

2. The application form shall be submitted at the respective Sub - Regional Officer of the
Board under whose jurisdiction the applicants activity falls.

3. The application shall be accompanied by the consent fee in the form of Demand Draft
in favor of Maharashtra Pollution Control Board. Fee paid is Not refundable

4. For the items marked * strike out which is not relevant

5. If any of the items is not relevant to the activity of the applicant, please state ‘Not
Applicable’.

6. If the space for reply provided for any item is inadequate, use additional sheets, duly
Referenced.

7. Item 1 Give the name of the person who is authorized by the applicant to transact their
Business.

8. Item 2 also state the concerned instructions under whose administrative area the unit
falls.

9. The form shall be accompanied by the relevant documents specified on the last page
of the Application.

10. Capital Investment -Consent fee is to be paid based on gross block investment of the
unit without depreciation till the date of application. The gross block capital investment
shall include cost of land, building, plant and machinery without depreciation same shall
be certified by Chartered Accountant. In case of proposed unit total project cost shall be
considered To be submitted in TRIPLICATE

Price Rs.One Hundred only-

 2-

PAYMENT OF CONSENT FEES.

The fee structure is as under -
Capital Investment Combined fees for Consent to Establish
Combined fees for 0Consent to Operate

Above 100 Crores 1,00,000/- 1,00,000/-

0 Crores to < 100 Crores 60,000/-

10 Crores to < 50 Crores 40,000/- 40,000/-

5 Crores to < 10 Crores 10,000/- 10,000/-

1 Crores to < 5 Crores 10,000/- 10,000/-

60 Lakhs to < 1 Crore 3,000/- 3,000/-

10 Lakhs to < 60 Lakhs 1,500/- 1,500/-

Less than 10 lakhs 500/- 500/-

Fees for Hazardous Waste Authorization under Hazardous Waste (Management

and Handling ) Rules, 2000 - Rs. 7,500/- for the period of 5 years.
_________________________________________________________________________________

The industries have been classified in different categories such as -

RED, ORANGE, GREEN depending on pollution potential. The above referred consent
fee for Combined Consent to Operate is for a period of 1, 2, 3 years for industries in

RED, ORANGE & GREEN;- Category respectively. The industries can opt for multiple
period of consent (maximum up to five times) by paying corresponding higher fee,
subject to their complying with requirement of installation of pollution control facilities.

Fees for Local Bodies (under Water (P.&.C. P.) Act, 1974 only.

Municipal Corporation Rs. 20,000/-

“A” Grade Municipal Corporation Rs. 10,000/-
“B” Grade Municipal Corporation Rs. 5,000/-
“C” Grade Municipal Corporation Rs. 2,000/-

Consent fees should be paid by way of Demand Draft drawn in favor of

“MAHARASHTRA POLLUTION CONTROL BOARD” only.
Payable at the HQ of the concerned Sub-Regional Officer.
 Application for Consent / Authorization
Date :
From...........................................................
...........................................................
............................................................
............................................................

To,
The...............................................
Maharashtra Pollution Control Board,
……….................................................
............................................................

Sir,

I/We hereby apply for*

1. Consent to Establish/Operate/Renewal of consent under section 25 and 26 of the Water

(Prevention & Control of Pollution) Act, 1974 as amended.

2. Consent to Establish/Operate/Renewal of consent under Section 21 of the Air (Prevention and

Control of Pollution) Act, 1981, as amended.

3. Authorization/renewal of authorization under rule 5 of the Hazardous Wastes (Management

and Handling) Rules, 1989, as amended in January,2000, in connection with My/our/existing
/proposed altered/ additional manufacturing/processing activity from the premises as per the
details given below.

Part A General

1. Name, designation, office address with Telephone :

/Fax numbers, e-mail of the Applicant :
Occupier/Industry/Institution / Local Body. :

2. (a)- Name and location of the industrial unit/premises :

for which the application is made :
(Give revenue Survey Number/Plot number name :
of Taluka and District, also telephone and fax :
number) :

(b)- Details of the planning permission obtained from :

the local body/Town and Country Planning :
authority/Metropolitan Development authority/ :
designated Authority. :

(c)- Name of the local body under whose jurisdiction :

the unit is located and Name the license issuing :
authority :

3. Names, addresses with Telephone and Fax :

Number of Managing Director / Managing Partner :
and officer responsible for matters connected with :
pollution control and/or Hazardous waste disposal. :

Contd..
 --2--

4. (a)- Are you registered Industrial unit ? :

(b)- If yes, give the number and date of registration :

5. Gross capital investment of the unit without :

depreciation till the date of application :
(Cost of building, land,plant and machinery). :
(To be supported by an affidavit/undertaking on :
Rs.20/- stamp paper,annual report or certificate :
from a Chartered Accountant for proposed unit(s), :
give estimated figure) :

6. If the site is located near sea-shore/river bank/ :

other water bodies/Highway, Indicate the crow fly :
distance and the name of the water body, if any. :

7. Does the location satisfy the Requirements Under :

relevant Central/State Govt. Notification such as :
Coastal Regulation Zone. Notification on :
Ecologically Fragile Area, Industrial :
Location policy, etc. If so, give details. :

8. If the site is situated in notified industrial estate, :

(a)- whether effluent collection, treatment and disposal :
system has been provided by the authority. :

(b)- Will the applicant utilise the system, if provided. :

(c)- If not provided, details of proposed arrangement. :

9. (a)- Total plot area,/ :

(b)- Built up area and :

(c)- Area available for the use of treated sewage/ trade :

effluent for gardening/irrigation. :

10. Month and year of commissioning of the Unit. :

11. Number of workers and office staff. : Workers Staff

Hrs. Of shifts Weekly off

__________ __________ ________ _______

12. (a)- Do you have a residential colony Within the :

premises in respect of Which the present :
application is made ? :

(b)- If yes, please state population staying :

(c)- Indicate its location and distance with reference to :

plant site. :

Contd..
 --3--

13. List of products and by-products Manufactured in :

tons/month, Kl/month or numbers/month with :
their types i.e. Dyes, drugs etc. :
(Give figures corresponding to maximum installed :
production capacity :
14. List of raw materials and process chemicals with :
annual consumption corresponding to above :
stated production figures, in tons/month or :
kl/month or numbers/month. :
15. Description of process of manufacture for each of :
the products showing input, output, quality and :
quantity of solid, liquid and gaseous wastes, if any :
from each unit process. :
(To be supported by flow sheet and/or material :
balance and water balance sheet). :

Part B Waste Water aspects.

16. Water consumption for different uses m3/day) :

(i)- Industrial cooling, spraying in mine Pits or :
boiler feed, propultion of hydro generation sets. :
(ii)- Domestic purpose :
(iii)- Processing whereby water gets Polluted and :
the pollutants are Easily Bio-degradable. :
(iv)- Processing whereby water gets polluted and the :
pollutants are not easily Bio-degradable and are toxic. :

(v)- Other such as agriculture,gardening etc. (specify) Total -

17. Source of water supply,Name of authority granting :
permission if applicable and quantity permitted. :

18. Quantity of waste water (effluent) generated :

(m3/day):

(i) Domestic (vi) Cooling water blowdown

(ii) Industrial (vii) DM Plant/Softening
(iii) Process Plant washings.
(iv) Washings (viii)Tail race discharge from
(v) Boiler Blowdown Hydro power station.
19. Water budget calculations accounting for :
Difference between water consumption and effluent :
Generated. :
20. Present treatment of sewage/canteen effluent :
(Give sizes/capacities of treatment units). :
21. Present treatment of trade effluent :
(Give sizes/capacities of treatment units) :
(A schematic diagram of the treatment scheme :
with inlet/outlet characteristics of each unit :
operation/process is to be provided. Include details :
of residue Management system (ETP sludge) :

Contd..
 --4--

22. (a)- Are sewage and trade effluents mixed together? :

(b)- If yes, state at which stage -Whether before, :

intermittently or after treatment. :

23. Capacity of treated effluent sump, Guard Pond if :

any.

24. Mode of disposal of treated effluent With :

respective quantity, m3/day :

(i)- into stream/river (name of river) :

(ii)- into creek/estuary (name of Creek/estuary) :
(iii)- into sea :
(iv)- into drain/sewer (owner of sewer) :
(v)- On land for irrigation on owned land/lease land. :
Specify cropped area.:
(To be supported by relevant documents) :
(vi)- Quantity of treated effluent reused/ recycled, :
m3/day Provide a location map of disposal :
arrangement indicating the outlet(s) for sampling. :

25. (a)- Quality of untreated/treated effluents :

(Specify pH and concentration of SS, BOD,COD :
and specific pollutants relevant to the industry. :
TDS to be reported for disposal on land or into :
stream/river. :

(b)- Enclose a copy of the latest report of analysis :

from the laboratory approved by State Board/ :
Committee/Central Board/Central Government in :
the Ministry of Environment expected :
characteristics of the untreated/treated effluent :

Part - C Air emission aspects:

26. Fuel consumption Coal LSHS Furnace Natural Other: :
Oil Gas (Specify) :
(a) Fuel consumption (TPD/KLD) :
(b) Calorific value :
(c) Ash content % :
(d) Sulphur content % :
(e) Other (specify) :

27. (A) Details of stack :

(process & fuel stacks D. G. Set) :
(a) Stack number(s) 1. 2. 3. 4. :
(b) Attached to :
(c) Capacity - :
(d) Fuel type :
(e) Fuel quantity (Kg/hr.) :
(f) Material of construction :
(g) Shape (round/rectangular) :
(h) Height, m (above ground level) :

Contd..
 --5--

(i) Diameter/size, in meters :

(j) Gas quantity, Nm3/hr. :
(k) Gas temperature oC :
(l) Exit gas velocity, m/sec. :
(m)Control equipment preceding the stack :
(n) Nature of pollutants likely to present in the :
stack gases such as Cl2, Nox, Sox, TPM etc. :
(o) Emissions control system provided :
(p) In case of D.G. Set power generation :
capacity in KVA :

(Attach specifications including residue :

management systems of each of the Control :
equipment indicating inlet/outlet concentration of :
relevant pollutants) :

27. (B) Whether any release of odoriferous compounds :

such as Mercaptans, Phorate etc. Are coming out :
from any storages or process house. :

28. Do you have adequate facility for collection of :

samples of emissions in the form of port holes, :
platform, ladder\etc. As per Central Board :
Publication “Emission regulations Part-III” :
( December, 1985 ):

29. Quality of treated flue gas emissions and pro- :

cess emissions. Quantity of treated flue gas :
emissions and process emissions. :

(Specify concentration of criteria pollutants and :

industry/process-specific pollutants stack-wise. :
Enclose a copy of the latest report of analysis :
from the laboratory approved by State :
Board/Central Board/ Central Government in the :
Ministry of Environment & Forests. For proposed :
unit furnish expected characteristics of the :
emissions.:
Part - D Hazardous Waste aspect :
30. Information about Hazardous Waste Management as defined in Hazardous Waste (Management
& Handling ) Rules, 1989 as amended in Jan 2000.
Type/Category of Waste as per
Method of Collection Reception Storage Transport Treatment Disposal
Qty
Schedule-I Schedule-II kg/day Method of
Cat.No. Type Class Type
Collec- Recep- Stor Trans Treat Dispo-
tion tion age port ment sal

Please refer copy of Schedule-I & II attached

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31. Details about use of hazardous waste :

i)- Name of hazardous waste/Spent chemical :

ii- Quantity used/month :
iii)- Party from whom purchased :
iv)- Party to whom sold :

32. (a)- Details about technical capability and equipments :

Available with the applicant to handle the Hazardous Waste.:

(b)- Details about technical capability and equipments :

Available with the applicant to handle the Hazardous :
Waste Characteristics of hazardous waste(s) Specify :
Concentration of relevant pollutants. Enclose a copy :
of the latest report of analysis of from the laboratory :
Approved by State Board/Central Govt. in the ministry :
of Environment & Forests. For proposed units furnish :
Expected characteristics :

33. Copy of format of manifest/record keeping :

Practiced by the applicant. :

34. Details of self-monitoring (source and environ- :

ment system) :

35. Are you using any imported hazardous waste? If :

yes, give details.

36. Copy of actual user Registration/certificate :

Obtained from Ministry of Environment & Forests, :
Government of India, for use of hazardous waste. :

37. Present treatment of hazardous waste, if any :

(give type and capacity of treatment units) :

38. Quantity of hazardous waste disposal :

-1 Within factory :
-2 Outside the factories (specify location and enclose :
Copies of agreement.) :
-3 Through sale (enclosed documentary proof and :
Copies of agreement.) :
-4 Outside state/Union Territory, if yes particulars of :
(1 & 3 ) above. :
-5 Other (Specify) :

Part - E- Additional information :

39. (a) Do you have any proposals to upgrade the :
present system for treatment and disposal of :
effluent/emissions and/or hazardous waste :

(b)- If yes, give the details with time- schedule for the :
implementation and approximate expenditure to be :
incurred on it.:
 --7--

40. Capital and recurring (O&M) expenditure on :

various aspect of environment protection such as :
effluent, emission, hazardous waste, solid waste, :
tree-plantation, monitoring, data acquisition etc. :
(give figures separately for items implemented/to :
be implemented). :

41. To which of the pollution control equipment, :

separate meters for recording consumption of :
electric energy are installed ? :

42. Which of the pollution control items are connected :

to D.G. Set (captive power source) to ensure their :
running in the event of normal power failure. :

43. Nature, quantity and method of disposal of non- :

hazardous solid waste generated separately from :
the process of manufacture and waste treatment. :
(Give details of area/capacity available in :
applicant’s land) :

44. Hazardous Chemicals - Give details of Chemicals :

and quantities handled and Stored. :
(i)- Is the unit a Major Accident Hazard unit as per :
Mfg.Storage Import Hazardous Chemicals Rules ? :
(ii)- Is the unit an isolated storage as defined under the :
MSIHC Rules ? :
(iii)- Indicate status of compliance of Rules 5,7,10,11, :
12,13 and 18 of the MSIHC Rules. :
(iv)- Has approval of site been obtained from the :
concerned authority?:
(v)- Has the unit prepared an off-site Emergency Plan? :
Is it updated ? :
(vi)- Has information on imports of Chemicals been :
provided to the concerned authority :
(vii)- Does the unit possess a policy under the PLI Act? :

45 Brief details of tree plantation/green belt :

development within applicant’s premises :
( in hectres )

46 Information of schemes for waste Minimisatiion, :

resource recovery and recycling – implemented :
and to be implemented, separately. :

47. (a) The applicant shall indicate whether Industry :

comes under Public Hearing, if so, the relevant :
documents such as EIA, EMP, Risk Analysis etc. :
shall be submitted, if so, the relevant documents :
enclosed shall be indicated accordingly. :

(b) Any other additional information that the applicants :

desires to give :
(c) Whether Environmental Statement submitted ? If :
submitted, give date of submission : Yes/No
 --8--

48. I/We further declare that the information furnished above is correct to the best of
my/our Knowledge
49. I/We hereby submit that in case of any change from what is stated in this application
in respect of raw materials, products, process of manufacture and treatment and/or
disposal of effluent,
emissions, hazardous wastes etc. In quality and quantity; a fresh application for
Consent/Authorization shall be made and until the grant of fresh Consent/Authorization
no change shall be made.
50. I/We undertake to furnish any other information within one month of its being called
by the Board.
51. I/We enclosed herewith a Demand draft for Rs______________________________.
________________________________Drawn in favor of Maharashtra Pollution Control
Board as the fee for consent/authorization for a period upto_______________________

Yours faithfully,

Signature __________________________-

Name ______________________________

Designation _____________________________

Accompaniments -
1. Index /Site Plan showing the surrounding such as village, town, river, and sea shore,
Transport Routes etc.
2. Detailed layout plan of the factory premises showing structures, water supply line,
storm drain,
Sewers for domestic effluents, for trade effluents, location of effluent treatment and its
Disposal and any other useful information, drawing, tables etc.
3. Manufacturing process of each product with flow diagram & material balance.
4. Latest Joint Vigilance sample analysis report.
5. Details of air pollution control devices provided or proposed to be provided.
6. Ambient air quality report, if available.
7. Small Scale Industry’s Certificate/No Objection Certificate from Directorate of
Industries, Govt. Of Maharashtra/D.G.T.D. License.
8. Xerox copy of consent granted under Air & Water (P.&C.P.)Acts.
9. TLV of raw materials.
10. Gross block investment certificate from C.A./audited balance sheet.
11. Process flow sheet.
12. Chemical reactions involved in each process.
13. NOC from local body for proposed industry.
14. Water budget calculations