|
From,
Sri....................................................
M/s..................................................
...................................................
...................................................
To,
The Member Secretary,
U.P. Pollution Control Board,
Building No. TC-12 V, Vibhuti Khand,
Gomti Nagar, Lucknow-226 010
1. Particulars of
Applicant
(i) Name of the Applicant
(in block letters & in full )
(ii) Name of the Institution
(iii) Address
(iv) Telephone No.: Fax No.; Telex No.
2. Activities for which
authorisation is sought;
(Please tick mark appropriate
activity/activities)
(i) Generation
(ii) Collection
(iii) Reception
(iv) Storage
(v) Transportation
(vi) Treatment
(vii) Disposal
(viii) Any other form of handling
3. Please state
whether applying for fresh or renewal of Authorisation
(in case of renewal
previous authorisation No.& date )
4. i. Address of
the institution handling bio-medical wastes:
ii. Address of the place
of treatment facility:
iii. Address of the place of
disposal of the waste:
5. (i) Mode of
transportation (if any) of bio-medical wastes
(ii)
Mode(s) of treatments
6. Brief description of
method of treatment and disposal
(attach complete details
including operator of facility, site, disposal area)
7. (i) Category (see
Schedule I ) (ii) Quantity of wastes (category wise)
of Bio-medical wastes to be
handled & managed
1................................................
......................................
2................................................
......................................
3................................................
......................................
4................................................
......................................
5................................................
......................................
6................................................
......................................
8. Declaration
I do hereby declare that the statements made and
information given above are true to the best of my knowledge and belief ans
that I have not concealed any information.
I do also hereby undertake to provide any further information sought by the U.
P. Pollution Control Board in relation to these rules and to fulfill any
conditions stipulated by the U. P. Pollution Control Board.
| Place
:.....................
Date
:...................... |
Signature of applicant
Designation |
Annexure to Form 1
1. (a)
Details regarding institution
(1) Head /Chief Executive
(2) Owned by
(3) Fixed assets value Rs.
(b) Important environmental features of the surrounding
site
(Please attach a map of the area ,2.5 km radius with the site at
the centre indicating there in water bodies , important human
activities, sensitive features, other productive activities)
2. (i) A description
of different steps of bio-medical services such as surgery,
pathology
,radiography,
gynecological, postmortem, drug research,
bio-medical studies etc, of the
institution which generate
biomedical wastes as specified in the Rules.(Please state details )
(ii) No of patients treated in a month
(iii) No of beds in the hospital/nursing
home/institution
(iv) Details of laboratories/animal house etc
(in case
of a research institution)
3. Description of
Bio-medical Wastes
(a) Quantum of each type of waste generated per month
in terms of Schedule appended to the rules.
(b) Physical properties
(1) Physical form (solid/semi solid /liquid)
with respective quantity in each form
(2) Specific gravity
(3) Percentage solids
(4) Moisture content
(5) Loss on ignition
(c) Composition (State details for each type)
(i) Expected pathogens
(ii) Metallic contents
(iii) Rubber/Plastics
(iv) others (specify)
(d) Details of discarded/time barred medicines
(e) Details of discarded appliances, accessories,
consumables etc
5. Method of packaging
and labeling of wastes of each type of waste
(i) Whether wastes are being segregated according to
type of wastes
(ii) Type of Containers, size & number
(iii) Is the packaging /labeling in accordance with
Rules
notified under E.P.Act 1986.Please give details
6. Method of handling
and transport
(i) By hand /trolley/tractor/truck/or any other means
(ii) Name of transporter/scrap contractor
(iii) RTO number of vehicles
(iv) Is the transport in accordance with Rules If yes,
details thereof
under Motor vehicles Act 1988?
(v) Is the manifest system being followed If yes,
details thereof
(vi) Is the TREM Card being issued If yes, details
thereof
7. Method of treatment of
wastes
a.Give details of treatment facility with map, diagrams,
type of treatment such as physical, chemical, biochemical, incineration
,microwave, autoclave etc.
b. Quantity of leachate generated m/d
c. Analysis report of leachate, if available from a
laboratory
approved under Environment (Protection) Rules
- pH
- TOC
- BOD
- COD
- TDS
- Heavy metals
- Oil & grease
- Phenolics
- Cyanides
- Pesticides
- Toxicity
- others, specify if any
8. Method of Temporary
Storage
Give details such
capacity, material of construction,
covered or open to
sky,leachate collection etc
9. Bio-medical waste
disposal
- Give details such as the
operator of facility, location and capacity, construction, details, leachate
collection and treatment etc.
- Whether disposal area is restricted with fencing, if
so give details and the
security arrangements.
- Whether disposal facility
is a common facility or individual, in case of
individual site also give details of land, ownership, size etc.
10. Safety measures adopted regarding
handling and management of
bio-medical wastes.
Please furnish activitywise details for all stages as follows:-
(Please give specific
details for each activity
(i) Generation
(ii) Segregation & collection
(iii) Treatment at site
(iv) Temporary storage
(v) Transportation to common /individual facility
(vi) Treatment
(vii) Disposal
(viii) Any other form of handling
11. Environmental surveillance
reports at treatment and disposal facility
12. Whether complete records are
maintained for bio-medical wastes if so,a copy
of last two months shall be
enclosed
13. Relative percentages of total wastes
generated:-
i. Pathogenic wastes
ii. Infectious wastes
iii. General non-infectious wastes
iv. Food wastes
v. Liquid wastes
14. Any other details regarding handling
and management of
bio-medical wastes
NOTE:
- The occupier of unit/operator of facility fill Form-1
- The records of bio-medical wastes are to be maintained by the applicant
- The applicant has to submit returns on Form-4 to U. P. Pollution Control
Board.
- Any accident during transport to the facility or at the site has to be
reported immediately to U.P. Pollution Control Board.
- A demand draft of Rs. payable to U.P. Pollution Control Board towards
processing fee of the application has to be enclosed.
- Please attach
documents wherever required.
I
........................................................of
M/s...................................................
is authorized by above said institution and the chief executive of the
institution have read the Form and annexures attached and that I understand that
the above information is correct.
| Place
:.....................
Date
:...................... |
Signature of applicant
Seal |
|
