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[Environment Conservation Rules, 1997]
FORM – 3
Application for Environmental Clearance Certificate
[See Rule 7(5)]
Director/Deputy Director,
Department of Environment,
Dhaka Division/Chittagong Division/Khulna Division/Rajshahi Division (Bogra).
Sir,
I do hereby apply for Environmental Clearance Certificate for my proposed industrial unit or
project, or for the existing industrial unit or project, and enclose papers and furnish
information as follows :
1.(a) Name of the industrial unit or project
Address of location of the industrial unit or project
:
:
(b) Address of present office :
2.(a) Proposed industrial unit or project
: Expected date of starting construction :
: Expected date of completion of construction :
: Expected date of trial production in case of
industrial unit, in other cases, date of starting
operation of the project
:
(b) Existing industrial unit or project
: Date of starting trial production in case of
industrial unit, in other cases, date of starting
operation of the project
:
3. Name of product and quantity to be produced
(daily/monthly/yearly)
:
4.(a) Name of raw materials and quantity required
(daily/monthly/yearly)
:
(b) Source of raw material :
5.(a) Quantity of water to be used daily :
(b) Source of water :
6.(a) Name of fuel and quantity required
(daily/monthly/yearly)
:
(b) Source of fuel :
7.(a) Probable quantity of daily liquid waste :
(b) Location of waste discharge :
(c) Probable quantity of daily emission of gaseous
substance
:
(d) Mode of emission of gaseous substance :
8. Mouza (village) map indicating “Daag” (plot)
number and “Khatiyan” (land tax account) number
:
9. Approval of Rajdhani Unnayan Katripakkhya/
Chittgong Development Authority/Khulna
Development Authority/ Rajshahi Development
Authority (if applicable).
:
10.(a) Design & time schedule of proposed Effluent
Treatment Plant
:
(b) Fund allocated :
(c) Area :
11. Process Flow Diagram :
12.(a) Location map of industrial unit or project :
(b) Layout plan (with location of Effluent Treatment
Plant)
:
13.(a) IEE/IEA report* (if applicable) :
(b) Environmental Management Plan* (if applicable) :
14. Feasibility Report (if applicable) :
Seal Signature of the entrepreneur
Name :
Address:
Phone :
Date :
-: Declaration :-
I do hereby declare that all information provided by me in this application are true to the
best of my knowledge and no information has been concealed or distorted herein.
(Name & signature of entrepreneur)
* Each page be countersigned by the person who fills out this application form and
by the entrepreneur.
[Form-3 Contd.]