SCHEDULE IV
FORM A [Regulation 16(b)]
National Environmental Act, No 47 of 1980 (Section 23 A)
FORM OF APPLICATION FOR A LICENCE FOR SCHEDULED WASTE MANAGEMENT
Application No:
Date :
Sector :
Category :
01. Name of the facility/activity:
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02. Location/ address
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03. Telephone No. :……………………………………………………
04. Local Authority area :…………………………………………….
05. District :……………………………………………………………..
06. Province :……………………………………………………………
07. Name of the Officer/Person to be contacted in an emergency:
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08. Contact details :
Mobile phone: ………………………..
Tel : ………………………..
Fax : ………………………..
Email : ………………………..
Address : ………………………..
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09. Authorization required for (Please tick appropriate activity/activities)
(a) Generation ( )
(b) Collection ( )
(c) Transportation ( )
(d) Storage ( )
(e) Recovery ( )
(f) Recycling ( )
(g) Disposal ( )
( ) Permit for one operation ( ) Permit for multiple operations
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10. Full Name of the Applicant/Industry :
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11. Contact details
Address: ………………………………………………………
Tel No: ………………………………………………………
Fax No: ………………………………………………………
12. In case of renewal of licence, previous licence number and date:
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13. Qualifications to engage in the activity covered by the permit:
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14. Insurance cover details:
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15. Arrangements for security and emergency procedures:
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16. Information on accidents as a result of the management of waste:
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17. Health and safety measures adopted for the workers and the public:
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18. Important Environmental features of the surrounding areas of the site (Please attach a map of the
area 2.5 km radius with the site at the centre indicating therein water bodies and important human
activities, sensitive features):
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19. Waste category/categories identified as per the Schedule VIII:
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20. Quality and quantity waste handled:
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21. Details of the operation system for carrying out the activity / activities:
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22. If application is for the establishment of a disposal site, location description and other details:
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To be filled by Collector
23. Site/s of Collection ( Names and address/es) :
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24. Proposed dates or frequency of collection:
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25. Estimated quantity to be collected:
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26. Type of packaging envisaged (Eg. bulk, drummed, tanker etc) and method of collection:
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To be filled by transporter
27. Mode of transportation to be used:…………………………………………………………
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Class/type of vehicle:………………………………………………………………………….
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Registered number/s:…………………………………………………………………………
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Number of vehicles:…………………………………………………………………………….
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28. Details of Routes (include road maps) times and dates:
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29. What are the emergency measures adopted (including notice of warning to the public) and what
are the precautions taken to prevent accidents:
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To be filled by Storer
30. Location and extent of the storage site:
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31. Type of packaging envisaged (bulk, drummed, tanker, concrete blocks etc) for storing:
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32. Period of time waste will be stored:
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33. Information relating to recycling / recovery of final disposal of the waste:
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34. What are the emergency measures adopted (including posting notices of warning to public ) and
what are the precautions taken to prevent accidents:
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To be filled by recycler / recoverer:
35. Location of the recycling / recovery facility
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36. Method used in the recycling / recovery process:
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37. Purpose of recycling / recovery and the market availability for the end product
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38. Emergency measures adopted in the event of an accident:
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To be filled by Disposer:
39. Location of the site for Disposal:
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40. Method of Disposal:
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41. Description of the treatment process:
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42. Emergency measures adopted at the site in the even of an accident:
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43. Information on the after care of the disposal site:
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Signature of the Applicant
Date : …………………………..
