Form XXIII

(See rule – 117 (2))

APPLICATION FOR APPROVAL OF PLANS OF FACTORY

Hazardous Nature of Factory: Hazardous/Non-Hazardous

1) Plan Type: New / Extension/Revision History

2) Name of the Factory:

3) Full Address and location of the site/factory:

4 a) Communication Address:

b) Email Address:

5) Number of employees to be employed: Men: Women:

6) Installed horsepower: Regular: HP Standby power:

KVA

7) List of plant and machinery (Upload):

8) Raw Materials used and maximum Quantities stored in the

Manufacturing (Upload):

9) Brief Description of Manufacturing Process: (Upload)

10) Final Products and their output capacities: Upload

11) Type and Nature of wastes and effluents, their quantities and

Methods of their disposal :( Upload)

12) In case of extensions or additional installation, reference numbers

of plans approved earlier:

Sl.NO New / Revision Approved letter

number

13) Type of industry: Hazardous / non-hazardous

14) Signature of Occupier with name & designation :( Upload)

Signature of Occupier

Enclosures for Plan approval:

a) Registered Sale Deed / Lease Deed:(Upload)

b) Site Plan :( Upload)

c) Detailed Building Plan :( Upload)

d) Partnership Deed / Memorandum of Articles of Association :(

Upload)

e) Process Flow Chart :( Upload)

f) Copy of PAN Card / Aadhar Card of applicant :( Upload)

g) MSDS of chemical

h) Appropriate Risk assessment reports,

i) Operability Study.

j) Arrangements proposed for effective removal of dust, fumes,

gases and disposal of trade wastes and effluents etc.

k) List of Director/Partner