Form XXVII

[(See Rule-68(iii)]

FORMAT OF APPLICATION TO THE SITE APPRAISAL COMMITTEE

1. Name and address of the applicant

2. Site Ownership Data

2.1 Revenue details of site such as Survey No. Plot No. etc.

2.2 Whether the site is classified as forest and if so, whether approval of the Central

Government under Section 5 of the Indian Forests Act, 1927 has been taken.

2.3 Whether the proposed site attracts the provisions of Section 3(2) (v) of the E.P.Act, 1986,

if so, the nature of the restrictions.

2.4 Local authority under whose jurisdiction the site is located.

3. Site Plan

3.1 Site Plan with clear identification of boundaries and total area proposed to be occupied

and showing the following details nearby the proposed site.

(a) Historical monument, if any, in the vicinity.

(b) Names of neighboring manufacturing units and human habitats, educational and

training institutions, petrol installations, storages of LPG and other hazardous

substances in the vicinity and their distances from the proposed unit.

(c) Water sources (rivers, streams, canals, dams, water filtration plants, etc.) in the

vicinity. (d) Nearest hospitals, fire stations, civil defence stations and police

stations and their distances.

(e) High tension electrical transmission lines, pipelines for water, oil gas or

sewerage; railway lines, roads, stations; jetties and other similar installations.

3.2 Details of soil conditions and depth at which hard strata obtained.

3.3 Contour map of the area showing nearby hillocks and difference in levels.

3.4 Plot Plan of the factory showing the entry and exit points, roads within, water drains, etc.

4. Project Report

4.1 A summary of the salient features of the Projects.

4.2 Status of the organisation (Government, Semi Government, Public or Private etc.)

4.3 Maximum number of persons likely to be working in the factory.

4.4 Maximum amount of power and water requirements and source of their supply.

4.5 Block diagram of the buildings and installations, in the proposed supply.

4.6 Details of housing colony, hospital, school and other infrastructural facilities proposed.

5. Organisation structure of the proposed manufacturing unit/factory

5.1 Organisation diagrams of – - Proposed enterprise in general - Health; Safety and

Environment protection departments and their linkage to operation and technical

departments.

5.2 Proposed Health and Safety Policy.

5.3 Area allocated for treatment of wastes and effluent.

5.4 Percentage outlay on safety, health and environment protection measures.

6. Meteorological data relating to the site

6.1 Average, minimum and maximum of - Temperature - Humidity - Wind velocities during

the previous ten years

6.2 Seasonal variations of wind direction

6.3 Highest water level reached during the floods in the area recorded so far.

6.4 Lightning and seismic data of the area.

7. Communication Links

7.1 Availability of telephone/telex/wireless and other communication facilities for outside

communication.

7.2 Internal communication facilities proposed

8. Manufacturing Process Information

8.1 Process flow diagram

8.2 Brief write-up on process and technology

8.3 Critical process parameters such as pressure buildup temperature rise and run- away

reactions

8.4 Other external effects critical to the process having safety implications, such as ingress of

moisture or water, contact with incompatible substances, sudden power failure.

8.5 Highlights of the built-in safety/pollution control devices or measures/incorporated in

the manufacturing technology.

9. Information of Hazardous Materials

9.1 Raw materials, intermediates, products and by-products and their quantities (Enclose

Material Safety Data Sheet in respect of each hazardous substance)

9.2 Main and intermediate storages proposed for raw materials/intermediates/products/by-

products (maximum quantities to be stored at any time).

9.3 Transportation methods to be used for materials inflow and outflow, their quantities

and likely routes to be followed

9.4 Safety measures proposed for: - handling of materials; - internal and external

transportation; and - disposal (packing and forwarding of finished products)

10. Information on Dispersal/Disposal of Wastes and Pollutants

10.1 Major Pollutants (gas, liquid, solid) their characteristics and quantities (average and at

peak loads)

10.2 Quality and quantity of solid wastes generated, method of their treatment and disposal

10.3 Air, water and soil pollution problems anticipated and the proposed measures to

control the same, including treatment and disposal of effluents.

11. Process Hazards Information

11.1 Enclose a copy of the report on environmental impact assessment

11.2 Enclose a copy of the report on Risk Assessment study.

11.3 Published (open or classified) reports, if any, on accident situations/occupational health

hazards or similar plants elsewhere (within or outside the country)

12. Information of proposed Safety and Occupational Health Measures

12.1 Details of fire fighting facilities and minimum quantity of water, CO2 and or other fire

fighting measures needed to meet the emergencies

12.2 Details of in-house medical facilities proposed

13. Information on Emergency Preparedness

13.1 Onsite emergency plan

13.2 Proposed arrangements, if any, for mutual aid scheme with the group of neighboring

factories

14. Any other relevant information

I certify that the information furnished above is correct to the best of my knowledge and

nothing of importance has been concealed while furnishing it.

Name and Signature of the Applicant.