Form XXXVII

[See Rule 84A (5)]

Application for Site Appraisal under Section 83 of the Code

Name and address of the applicant:

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 Forest Act, 1927 has been taken.

2.3 Whether the proposed site attracts the provisions of Section 3(2)(v) of the Environment (Protection)

Act, 1986; if so, the nature of the restrictions.

2.4 Local authority under whose jurisdiction the site is located.

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 neighbouring 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.

Project report:

4.1 A summary of the salient features of the project.

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 unit.

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

Organisation structure of the proposed manufacturing unit / factory:

5.1 Organisation diagram of:

(i) Proposed enterprise in general;

(ii) 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.

Meteorological data relating to the site:

6.1 Average, minimum and maximum of –

(i) Temperature

(ii) Humidity

(iii) Wind velocities during the previous ten years.

6.2 Seasonal variations of wind direction.

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

6.4 Lightning and seismic data of the area.

Communication links:

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

7.2 Internal communication facilities proposed.

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 build-up, temperature rise and runaway 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 built-in safety/pollution control devices or measures incorporated in the manufacturing

technology.

Information of hazardous materials:

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

Data Sheet for 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 for inflow and outflow of materials, their quantities and likely routes.

9.4 Safety measures proposed for:

(i) Handling of materials;

(ii) Internal and external transportation;

(iii) Disposal (packing and forwarding of finished products).

Information on disposal of wastes and pollutants:

10.1 Major pollutants (gas, liquid, solid), their characteristics and quantities (average and peak loads).

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

10.3 Air, water and soil pollution problems anticipated and proposed control measures.

Process hazard information:

11.1 Copy of Environmental Impact Assessment Report.

11.2 Copy of Risk Assessment Study.

11.3 Published reports on accident situations or occupational health hazards in similar plants.

Information on proposed safety and occupational health measures:

12.1 Fire-fighting facilities and minimum quantities of water, CO₂ and other measures.

12.2 In-house medical facilities proposed.

Information on emergency preparedness:

13.1 On-site emergency plan.

13.2 Mutual aid arrangements with neighbouring factories.

Any other information.

Declaration:

I certify that the information furnished above is correct to the best of my knowledge and nothing of

importance has been concealed.

Name & Signature of Applicant

Date:

Address: