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Application Form for Environmental Clearance Certificate
[FORM ENV-3]
Application for Environmental Clearance
For Industrial Establishment
To
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Sir,
I hereby submit the following information for my proposed industrial establishment/ existing establishment for the application of site clearance/ environmental clearance certificate.
Industrial Name:
Locational address of the industry:
Present address of the office:
2. (A) Proposed industrial establishment
Potential Project cost:
Amount of land:
Probable date of commencement of construction:
Probable date of end of construction
Probable date of trial production of industrial establishments:
(B) Existing industry
Probable date of trial production of industrial establishments:
Total investment amount:
3. Whether the proposed project falls within the ecologically sensitive area or the restricted area mentioned in Schedule 9:
4. Name and quantity of the produced product (day/month/year):
5. (a) Name and quantity of raw materials (day/month/year):
(b) Source of raw materials:
6. (a) Daily total usage of water:
(b) Source of water:
7. (a) Name and quantity of fuel (day/month/year):
(b): Amount of electricity consumption (kwh) and source of electricity:
8. (a) Location map of industrial establishment:
(b) Lay out plan (where applicable, the location of the waste treatment plant is indicated):
9. (a) Description of the manufacturing process:
(b) Flow diagram of production process:
10. (a) Nature of solid waste:
(b) Daily possible amount of solid waste:
11. (a) Daily possible amount of liquid waste:
(b) Discharge point of liquid waste:
12. Nature of gaseous pollutants and its mode of emission:
13. Possible source of sound pollution and mitigation management:
14. Solid waste management system:
15. Liquid waste treatment system (if necessary)*:
16. Air pollution control system (if necessary)**:
17. Measures adopted for occupational health protection and safety:
18. Land schedule and mouza map:
19: Permission letter from RAJUK/ Chattogram Unnoyan Kortripokkho/ Khulna Unnoyan Kortripokkho/ Rajshahi Unnoyon Kortripokkho/ Local Government (if necessary):
20. (a) Scope of preliminary Environmental survey report/ Environmental impact assessment report (if necessary):
(b) Environmental management plan (if necessary):
21. Feasibility study report (if necessary):
22. Others important information (if necessary):
Name of the entrepreneur (with seal)
Name:
Address:
Phone:
Email:
Date:
Declaration:
I, hereby declare that, the information given in the application form is true to the best of my knowledge and no information has been concealed or distorted.
Name of the entrepreneur and signature