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Duly completed form alongwith necessary attachments are to be submitted in single copy

WEST BENGAL POLLUTION CONTROL BOARD

Paribesh Bhawan,10A, Block – LA, Sector III, Salt Lake
Kolkata – 700 098, INDIA; Ph 335 9088,& Fax : (0091) (33) 335 8073

Application for Consent to Operate for Red & Orange Category Industries
Application for Consent to Operate for discharge of effluent, under Section 25 and Section
26 of Water (Prevention and Control of Pollution) Act, 1974 and emission/continuation of
emission under Section 21 of the Air (Prevention and Control of Pollution) Act, 1981.
Date of Submission
From : ...............................................................................………
................................................................................………
...............................................................................…….…
...............................................................................…….…
(Name and Address of the Unit)

To : The ...............................................................................….
................................................................................………
...............................................................................…….…
...............................................................................…….…

Sir,
1. I/We hereby apply in one application form for both consent to operate (Fresh/Renewal) (i) under sub-
section (2) of Section 25 and Section 26 of Water (Prevention and Control of Pollution) Act, 1974 to
make discharge from land/premises and (ii) under sub-section (2) of Section 21 of the Air (Prevention
and Control of Pollution) Act, 1981 to make emission from industrial plant owned by ……………….
………...............…………………………………………………. for a period upto …………………..
2. The Annexure, Appendices, other particulars and plans are attached .
3. I/We further declare that the information furnished in the application form, Annexure/Appendices
and plans is correct to the best of my /our knowledge.
4. I/We hereby submit that in case of a change either of a point or the quantity of discharge or the
quantity of emission, a fresh application for consent shall be made and until such consent is granted,
no change shall be made.
5. I/We hereby agree to submit to the Board, application for renewal of consent two months in advance
of the date of expiry of the consented period, if to be continued thereafter.
6. I/We undertake to furnish any other information within seven days of its being called for by the State
Board.
7. I/We enclose herewith UBI Challan of Rs........................(Rupees.…………............…………....)
deposited at ..………………………............................. Branch on ………………… in favour of
West Bengal Pollution Control Board being the ‘Consent to Operate application fee’.

Date (Signature.……............................)
Seal………………………………
Name of the applicant ....................................................................................………………..
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Designation ............……..........................................……….........................………
Application on behalf of ………............................................................................………………
Address of applicant ..............................................................................……………………..
..............................................................................……………………..

PART - A : (GENERAL INFORMATION)

01. Full name and address of the factory (mentioning Post Office, :
Police Station, Local body with Ward No. etc.)
..............................................................................……………….............………………………
..............................................................................……………….............………………………
..............................................................................……………….............………………………
Telephone ………………………………… Fax …………………………………
Police Station ……………………. P. O. & Pin Code …..……………………………..
J.L. No. …………………………………………………… Ward No………………………
Plot No. & Dag No. ………………………………………..………………………………….

02. Full address of the Registered Office/City Office :

..............................................................................……………….............………………………
..............................................................................……………….............………………………
..............................................................................……………….............………………………
Telephone ……………………………………………… Fax …………………………………
E-mail ………………………………………………….. Website ……………………………..

03. a) Size of industry (Large / Small) : ..……………………..……

b) Power Supply Agency at the factory premises

[viz. C.E.S.C/W.B.S.E.B/Others (Specify)] : ..……………………..……

04. Year of commissioning of the industry : ..……………………..……

05. (i) Number of persons engaged by the factory

a) Workers/Labourer (including contract engagements) : ..……………………..……
b) Management Staff : ..……………………..……
c) Others (Night watchman etc.) : ..……………………..……

(ii) a) No. of working hour per day: : ..……………………..……

b) No. of working day per year: : ..……………………..……

06. Population residing in the Quarters / Colony, if applicable : ..……………………..……

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07. Gross capital investment on land, building, plant & machinery Rs. …………………..…….
excluding capital investment on pollution control system of
the unit till the date of application

(To be supported by an undertaking, affidavit annual report or

certificate from a Chartered Accountant),

08. Give the list of raw materials (including fuel) with consumption
per month (If the space provided below is found inadequate, please attach :
separate sheet giving information using the same format )

Sl. No. Name of Raw Materials(including fuel) Quantity per Month

............. ......................................................................…………. ........................
............. ......................................................................…………. ........................
............. ......................................................................…………. ........................

09. List of products and by-products manufactured :

(If the space provided below is found inadequate, please attach separate
sheet giving information using the same format )

Name Production Average

Capacity Production
(Per Month) (Per Month)

................................................................................ ................................ ........................

................................................................................ ................................ ........................

................................................................................ ................................ ........................

................................................................................ ................................ ........................

PART-B : INFORMATION REQUIRED IN CONNECTION WITH PREVENTION

AND CONTROL OF WATER POLLUTION

10. Water consumption for different uses

Type of Use Sources of supply Quantity (M3/day)

(Strike out which is/are not applicable)

Industrial cooling, spraying in Municipal supply / Well / Tube well / ..............................….

mine pits / boiler pits Canal / River/Others (please specify)
Domestic purpose Municipal supply / Well / Tube well / ..............................….
(drinking, bathing, canteen use, etc.) Canal / River / Others (please specify)
Processing whereby water gets Municipal supply / Well / Tube well / ..............................….
polluted and the pollutants are Canal / River / Others (please specify)
easily biodegradable
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Processing whereby water gets Municipal supply / Well / Tube well / ..............................….
polluted and the pollutants are Canal / River / Others (please specify)
not easily biodegradable

11. Information regarding liquid waste dischagred

(Do not give information on storm water discharge)

Outlet Nature Sources Quantity Place of

No. (Industrial / Domestic / Mixed) (Place of generation) (M3/day) discharge

......... .......................................... ................................. ........................ ..................

......... .......................................... ................................. ........................ ..................

......... .......................................... ................................. ........................ ..................

(If the space provided above is found inadequate, please attach separate sheet giving information the same format)
(Note : Please attach a diagram showing liquid waste flow from its place of generation upto the of final discharge.)

12. Whether facilities available for liquid waste treatment : Yes / No

if yes,
(a) Quantity of Liquid waste treated : ..............................….

(b) Describe the facility along with a diagram : ..............................….

(Please attach separate sheet)

13. Attach latest ‘analysis report’ of the Board or Board’s : .............................….

recognised laboratory showing quality of liquid waste
discharge (before and after treatment)

14. Whether water meter at water intake points installed : Yes / No

15. Whether energy meter of E.T.P. installed : Yes / No

16. Whether wastewater flow measuring device installed : Yes / No

PART - C : INFORMATION REQUIRED IN CONNECTION WITH PREVENTION AND

CONTROL OF AIR POLLUTION
17. Details of source of emission 

(A) (from manufacturing process) : ...............………………….

Name the unit operations causing emission of pollutants
(Please attach additional sheet if required) : ...............………………….

: ...............………………….

: ...............………………….
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: ...............………………….

: ...............………………….

(B) (from Furnaces, Heaters, Kiln etc.)

Type of Furnace / Heaters / No. of Capacity of each unit Fuel used (nature & quantity)
Kiln Units in individual Furnace

...............………………….. .............. ...............…………… ...............……………………..

...............………………….. .............. ...............…………… ...............……………………..

...............………………….. .............. ...............…………… ...............……………………..

...............………………….. .............. ...............…………… ...............……………………..

...............………………….. .............. ...............…………… ...............……………………..

(C) from Boilers

Number of boilers Capacity of each Fuel used (nature & quantity) in

boiler individual boilers

...............………. ...............…………… ...............………………

...............………. ...............…………… ...............………………

...............………. ...............…………… ...............………………

(D) (from Diesel Generator Sets)

i) No. of DG Sets :

ii) Capacity of each DG sets :

iii) Height of the stack above DG room :

iv) Height of the DG room :

v) Noise pollution control measures

a) Acoustic enclosure/acoustic treatment

of DG room :

b) Exhaust muffler :
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18. Emission details

Stack Stack attached to Fuel Inner diameter Height from Flow Particulate SO2 Others pollutants, Description of air Pollution
No. (Type & ground rate Matter if any control devices,
Quantity) Top Bottom Nm3/hr mg/Nm3 mg/Nm3 if any

(If the space provided above is found inadequate, please attach separate sheet giving information using the same format)
(Attach latest ‘analysis report’ of the Board and Board’s recognised laboratory)
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PART - D : OTHER INFORMATION

19. Give details regarding solid waste

Type of Waste Description of waste Quantity per Method of disposal

(Lump/Paste/Dust, etc.) month
Waste from Process

Waste from liquid effluent treatment

Waste from Air Pollution Control Units

Rejected materials/Scrap

20. Attach a separate sheet (not applicable to small scale unit) :

providing a brief write-up and schematic flowsheet
of the manufacturing process clearly showing sources
of generation of solid (hazardous and, non-hazardous)
liquid and gaseous wastes

21. Attach layout plan clearly showing the different outlets for :
liquid waste discharge

22. Other relevant information, if any :

(Please attach separate sheet if required)

Seal Signature of Applicant........................................

Check-list of accompaniments:[Please put tick mark (√ ) as applicable]

The THIRD PART of the challan (in original) as proof of deposition of consent application fee
Undertaking/Affidavit/Annual Report/Certificate from a Chartered Accountant (Item No.07)
Additional sheet against Item No.08
Additional sheet against Item No.09
Additional sheet against Item No.11
Additional sheet against Item No.12 (b)
Additional sheet against Item No.13
Additional sheet against Item No.17 (A)
Additional sheet against Item No.18
Additional sheet against Item No.20
Additional sheet against Item No.21
Additional sheet against Item No.22

Notes : ⇒ All enclosures, documents and analysis reports of Board’s recognised laboratories must be
signed/counter-signed by the applicant with official seal.
⇒ All subsequent correction in the application form and enclosures should be signed by the applicant or
any person authorised by the applicant.
⇒ The form is to be filled preferably in by typewriting or legible hand writing