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Form-3
Application Form for Locational Clearance/Environmental Clearance
[Sub-rule (1) of Rule 9, Sub-rule (1) of Rule 10, Sub-rule (1) of Rule 11, Sub-rule (1) of Rule 12,
Sub-rule (1) of rule 14 and sub-rule (4) of rule 23]
For Industrial Establishments
To,
…………………………………….
…………………………………….
…………………………………….
…………………………………….
Sir,
I have submitted the documents along with the information provided for my proposed industrial
establishment/existing industrial establishment
Name of Industrial Establishment:
Locational Address of Industrial Establishment:
Present office address:
(a) Proposed Industrial Establishments:
Probable project cost:
Extent of land:
Probable date of commencement of construction:
Probable Date of Completion of Construction:
Probable date of trial production of industrial establishments:
(b) Existing industrial establishments:
Date of Commencement of Trial Production in case of Industrial Grant:
Total amount invested:
Whether the proposed project falls under the Environmental Threat Area or Prohibited Area mentioned in Schedule-9:
Product Name and Amount (Daily/Monthly/Annual):
(a) Name and Amount of Feedstock (Daily/monthly/Annually):
(b) Source of raw material:
(a) Amount of daily water consumption:
(b) Source of water:
(a) Name and Amount of Energy (Daily/Monthly/Annual):
(b) Amount of electricity consumption (in kilowatt-hours) and source of electricity:
(a) Location Map of Industrial Establishments:
(b) Lay-out plan (where applicable, location of refinery indicated):
(a) Details of the manufacturing process:
(b) Flow diagram of the production process:
(a) Solid wastage type:
(b) amount of daily potential solid wastage
(a) Amount of potential liquid waste per day (in cubic meters):
(b) Discharge point of liquid waste
Nature of Gaseous Viscera and its Mode of Emission:
Potential sources of noise pollution and noise control measures:
Solid Waste Management Procedures:
Liquid sewage treatment system (where applicable) *:
Air Pollution Control System (Applicable Grid) **:
Measures to be taken for occupational health and safety:
Land Schedule and Mauza Map:
Capital Development Authority/Chittagong Development Authority/Khulna Development Authority/Rajshahi Development Authority local authority permission letter (if applicable):
(a) Scope of Preliminary Environmental Survey Report/Environmental Impact Assessment Report (where applicable):
(b) Environmental Management Plan (where applicable): [EMP Checklist]
Feasibility Study Report (if applicable): [Project Profile]
Other information required (if applicable):
Signature of Entrepreneur (with seal) Name:
Address:
phone:
E-mail:
Date:
Declaration:
I hereby declare that the information given in the application form is true to the best of my knowledge and no information is concealed or distorted therein.
(Name and Signature of Entrepreneur) _ _
Note:
*According to schedule 12 documents related to liquid waste treatment must be submitted. [if any liquid waste]
**Documents related to air pollution control have to be submitted. [for air pollution control]
*** Every page should bear the signature and seal of the entrepreneur or his representative.