Form of application to Site Appraisal Committee

1. Name and address of the applicant:

2. Site ownership date:

a. Revenue details of site such as survey number, plot number, etc:

b. 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:

c. 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:

3. Local authority under whose jurisdiction the site is located:

4. Site plan:

a. Site plan with clear identification of boundaries and total area proposed to be occupied

and showing the following details nearby the proposed site:

i. Historical monuments, if any, in the vicinity:

ii. 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:

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

vicinity:

iv. Nearest hospitals, fire stations, civil defence stations and police stations and their

distances:

v. High tension electrical transmission lines, pipelines for water, oil, gas or

sewerages, railway lines, roads, stations, jetties and other similar installations:

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

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

d. Plot plan of the factory showing the entry and exit points, roads within, water drains etc.:

5. Project report:

a. A summary of the salient features of the project:

b. Status of the organisation (Government, Semi-Government, Public or Private etc.):

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

d. Maximum amount of power and water requirements and source of their supply:

e. Block diagram of the buildings and installations, in the proposed site:

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

6. Organisation structure of the proposed manufacturing unit/factory:

a. Organisation diagram of:

i. Proposed enterprise in general:

ii. Health safety and environment protection departments and their linkage to

operation and technical departments.

b. Proposed to health and safety policy:

i. Area allocated for treatment of waste and effluents:

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

7. Meteorological data relating to the site:

a. Average minimum and maximum of-

i. Temperature

ii. Humidity

iii. Wind velocity is during the previous ten years

b. Seasonal variations of wind direction

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

d. Lightening and Seismic data of the area

8. Communication links:

a. Availability of telephone/telex/wireless and another communication facilities for outside

communication:

b. Internal communication facilities proposed:

9. Manufacturing process information:

a. Process flow diagram:

b. Brief write-up on process and technology:

c. Critical process para-metres such as pressure build-up, temperature rise and run-away

reactions:

d. Other external effects critical to the process having safety applications, such as ingress of

the moisture or water contact with incompatible substances, sudden power failure:

e. Highlights of the build-in safety/pollution control devices or measures/incorporated in the

manufacturing technology:

10. Information of hazardous materials:

a. Raw materials, inter-mediate products and by-products and their quantities (includes

Material Safety Data Sheet in respect of each other order substance):

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

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

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

likely routes to be followed:

d. Safety measures proposed for-

i. handling of materials

ii. internal and external transportation

iii. disposal (packing/ forwarding of finished products):

11. Information on disposal/disposal of waste and pollutions:

a. Major pollutions (gas, liquid, solid) their characteristics and quantities (average and at

peak loads):

b. Quality and quantity of solid waste generated, method of their treatment and disposal:

c. Air, water and soil pollution problems anticipated and the proposed measures to control

the same, including treatment and disposal of effluent:

12. Process Hazard information:

a. Enclose a copy of the report on environmental impact assessment.

b. Enclose a copy of the report on risk assessment study.

c. Published (Open or Classified) reports, if any, on accident situations occupational health

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

13. Information of proposed safety and occupational health measures:

a. Details of firefighting facilities and minimum quantity of water, carbon-di-oxide and or

other fire-fighting measures needed to meet the emergencies:

b. Details of in-house medical facilities proposed:

14. Information on emergency preparedness:

15. On-site emergency plan

16. Proposed arrangements, if any, for mutual-aid scheme with a group of neighbouring factories

17. 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.