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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 :
[Form-3 Contd.]
7.(a) Probable quantity of daily liquid waste :
Location of waste discharge :
Probable quantity of daily emission of gaseous : substance
Mode of emission of gaseous substance :
Mouza (village) map indicating “Daag” (plot) : number and “Khatiyan” (land tax account) number
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
Fund allocated :
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.