APPLICATION NO: 2396097

Assam State Pollution Control Board

Consolidated Consent and Authorization (CCA)

Sir,
I / We hereby apply for *

Consolidated Consent and Authorization (CCA) under the Water (Prevention and Control of Pollution) Act,
1974, the Air (Prevention and Control of Pollution) Act, 1981, the Hazardous and Other Wastes
(Management and Transboundary Movement) Rules, 2016., and the Bio-medical Waste Management Rules,
2016 in connection with our existing / proposed project for the premises as per the details given below:

Part A: General :

1(a). Name and location of the Industry (including Name (as registered with SHREE GAUTAM
Hotels, HCF and any other service sector): other competent CONSTRUCTION CO.
Authorities (Department LTD
of Industries, Registrar
of Companies. etc.)
Address SHREE GAUTAM
CONSTRUCTION CO.
LTD JAMDUAR PT-I ,
CHIRAKUTA Dhubri
Patta/Dag No
Revenue Village/Town BILASIPARA
Revenue Circle
District Dhubri
Pincode 783348
1(b) Name, designation of the Applicant Name INDU DEVI SINGHI
Designation DIRECTOR
Mobile 7003424252
Email-id [email protected]
1(c) Geographical Co-ordinates : Lattitude : 26.234952:
Longitude
:90.275936com.lowagie.text.Font@e01feb1
1(d) Display Board as per PCBA’s notification dtd Upload photograph of DisplayBoard : :Yes
21/11/021 Upload Photograph of the Entire Plant : :Yes
2(a). Are you registered as a micro/small/medium No
(MSME)unit ?
2(b). If yes, upload registration certificates: No
3(a). Total Project Cost (In lakhs) 75.0

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3(b). To be supported by an Notarised affidavit or No
certificatefrom a Chartered Accountant, (If the land/
building is onrent/ the lease value for 10 years
should be included):
3(c).Details of D.G set Sr. No. Capacity
1 250KVA
3(d) Is the cost of D.G set included in the project No
Cost?
4. Name and Distance from nearby water body( if
any):
5. Name of the industrial estate, if applicable
6. Total plot area, Built-up area Plot Area : Bigha
Built-up Area : sq./meter
7. Month and year of proposed commissioning of the Month : October
unit(Actual Commissioning date) Year : 2010
8.Upload copy of CTE No
9. Upload copy of previous CTO No
10. Type of Business Manufacturing
11(a).Details of Raw materials (in Tonnes per
Annum or Kilo litres per annum):(only for product
manufacturing. This part to be disabled for service
sector)
Sr. No. Name Quanity Units
1 BLASTING AND 36000 TPA
RIVER BOULDER
11(b).Details of products and by-products
manufactured (TPA) / KLA corresponding to
maximuminstalled production capacity):(only for
product manufacturing. This part to be disabled for
service sector)
Sr. No. Name Quanity Units
Brand name (upload representative image of
product(s):
Upload images of Processing/Manufacturing area: No
11(c) Previous Year Production Details:(only for
product manufacturing. This part to be disabled for
service sector)
Sr. No. Name of Total Name of Raw Total Row Total water
Product production Material Material consumed
consumed
11(d) Manufacturing Process Flowchart.(only for No
product manufacturing. This part to bedisabled for
service sector)
11(e) Details of Hotel/Restaurant (To be active for
Hotel/restaurant only)
(i) Total number of rooms.

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(ii) Seating capacity of Restaurant
11.(f) Details of Storage facility (To be active for
storage facility/ Godown and Coal Storage only)
(i)Name of commodities stored
(ii)Storage capacity
11(h)Details of any other services
(i) Type of Service
(ii) Capacity
Part B: Water Consumption and Waste water
Generation
12 Water consumption for in Kilo Litres per
Day(KLD)
(i) Industrial 4.00
(ii) Domestic purpose 1.00
(iii) Others ( gardening) 1.00
13.(a) Source of ( Ground/ Public Supply/River Ground
intake):
13.(b) NOC from CGWA/ASGWA: Yes
14 Quantity of waste water (effluent)
generation(KLD):
(i) Industrial 0.00
(ii) Domestic 0.00
15. Effluent treatment capacity (in KLD)
16. Details of Effluent Treatment Plant/ Sewage N/A
Treatment Plant
17. Quantity of treated effluent reused / recycled (in 6
KLD)
Part - C: Air Emission Aspects
18. Sources of Emission:
(i) Furnace/Kiln/Oven:
Sr. No. Type of Capacit Type of Fuel
Furnace y fuel consum
/Oven/K ption(T
iln PH/
KLD/
Kl/Hr)
(ii) Boiler:
Sr. No. Type of Capacit Type of Fuel
Boiler y fuel consum
ption
(iii) Heaters ( for industries such as tea factories):
Sr. No. Type of Capacit Type of Fuel
Boiler y Heater consum
ption

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Part-D: Additional Information
20. Environmental Clearance
21. Whether the unit falls under the purview ofEIA No
Notification, 2006 , Environmental clearance(EC)?
22. Nature, quantity and method of disposal of various solid wastes:
(a) Total plastic waste generated (in TPA)
(b) Total Solid generated (in TPA) (Non-hazardous
Solid Waste etc.)
(c) Total E-Waste generated (in TPA)
(d) Scrap batteries generated (in TPA/ numbers per
annum)
(e) Mode of Storage No
(23) Tree plantation / green belt development in the
Industry premises (number of Trees planted)
(24) Any other additional information
(25) We further declare that the information furnished above is correct to the best of my / our knowledge.
Place :
Date:
Your faithfully :
Name :
Designation:

Part-2 .

Application for Authorisation under the Hazardous and Other waste (Management Handling and
Transboundary Movement) Rules , 2016.

FORM 1

Application required for grant/renewal of authorisation for generation or collection or storage or transport or reception or recycling or reuse or recovery or pre-processing or co-processing or utilisation or treatment or disposal of hazardous and other waste

Part A: General (to be filled by all)

1. (a)Name and address of the unit and location of facility : SHREE GAUTAM CONSTRUCTION CO.
LTD
(b) Name of the occupier of the facility or operator of disposal facility with designation, Tel, Fax and e-
mail: SHREE GAUTAM CONSTRUCTION CO. LTD DIRECTOR
(c) Authorisation required for (Please tick mark appropriate activity or activities:)

(i)Generation No
(ii)Collection No
(iii)Storage No
(iv)Transportation No

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 (v)Reception No
(vi)Reuse No
(vii)Recycling No
(viii)Recovery No
(ix)Pre-processing No
(x)Co-processing No
(xi)Utilisation No
(xii)Treatment No
(xiii)Disposal No
(xiv)Incineration No

(d) In case of renewal of authorization:) Not Attached

(e) Nature and quantity of waste stored at any time (in metric tonne or kilo litre):
Sr. No. Name of the Schedule- Category Quantity Remarks
Hazardous I/II/III/IV No. Stored at
waste any time
& (MTA/KLA
Other waste )

2.() Year of commissioning and commencement of production: 2010

3. Provide copy of the Emergency Response Plan (ERP): Not Attached

Part B: To be filled by hazardous waste generators

1. (a) Products and by-products manufactured (names and product wise quantity
(b) Process description including process flow sheet indicating inputs and outputs: Not Attached
(c) Characteristics (waste-wise) and Quantity of waste generation per annum:

Sr. No. Name of Schedule- Category Quantity Facility Remarks

the I/II/III/IV No.) Generate and Mode
Hazardou d per of
s waste Annum( Disposal
& MTA/KL
Other A)
waste
(d). Arrangement of Transportation: a) Sender b) Receiver;

(e). Details of the environmental safeguards and environmental facilities provided for safe handling of all
the wastes at point (c) above;;

2. Are hazardous chemicals as defined under the Manufacture, Storage and Import of Hazardous Chemicals
Rules, 1989 handled in your unit? If Yes,;

Part C: To be filled by Treatment, storage and disposal facility operators (enable for TSDFs)

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1. Provide details of the facility including;

(i) Location of site with layout map;

(ii) Safe storage of the waste and storage capacity;
(iii) The treatment processes and their capacities:
(iv) Secured landfills:
(v) Incineration,if any:
(vi) Leachatec ollection and treatment system;
(vii) Firefighting systems:
(viii) Environmental management plan including monitoring:
(ix) Arrangement for transportation of waste from generators:
2.Provide details of any other activities undertaken at the Treatment, storage and disposalfacility site.
3.Attacha copy of prior Environmental Clearance.

Part D: To be filled by recyclers or pre-processors or co-processors orusers of hazardous or other wastes (enable for Recyclers)

1. Nature and quantity of different wastes received per annum from domestic sources or imported or both:

Sr. No. Name of the Schedule- Category Quantity Source

Hazardous I/II/III/IV No. Received(M (Domestic/i
waste TA/KLA) mported
&
Other waste

2InProvide details of secured storage of wastes including the storage capacity:

3 Process description including process flow sheet indicating equipment details,inputs and outputs (input
wastes, chemicals, products, by-products, wastegenerated, emissions, waste water, etc.). Attach separate
sheets:

(iii) Provide details of end users of products or by-products:

Sl.No. Name of Product List of End User

5 Has the facility has incorporated Environmentally Sound technologies as per Central Pollution Control
Board guidelines?

6 Arrangements for transportation of waste to the facility:

Date………………..

Date………………..

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Application for obtaining Authorisation under the Bio Medical Waste Management Rules, 2016
(To be filled up by occupier of health care facility or common bio-medical waste treatment facility)

30. Activity for which authorisation is sought

Activity Please tick
Generation, segregation
Collection
Storage
Packaging
Reception (For CBWTF)
Transportation
Treatment or processing or conversion
Recycling
Disposal or destruction
Use
offering for sale, transfer
Any other form of handling
31. Application for authorisation
In case of renewal, previous authorisation
number and date:
32. GPS coordinates of health care
facility (HCF) or common bio-medical
waste treatment facility (CBWTF):
33. Details of health care facility (HCF)
or common bio-medical waste treatment
facility (CBWTF):
(i) Number of beds of HCF
(ii) Number of patients treated per month
by HCF :
(iii) Status of barcode implementation:
(iv) Quantity of Biomedical waste generated, handled, treated or disposed :
Category Type of Waste Quantity Method of
Generated or Treatment and
Collected, kg/day Disposal (Refer
Schedule-I)
(1) (2) (3) (4)
(a) Human
Anatomical Waste
(b) Animal
Anatomical Waste
(c) Soiled Waste
(d) Expired or
Discarded
Medicines

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Yellow (e) Chemical Solid
Waste
(f) Chemical Liquid
Waste
(g) Discarded linen,
mattresses,
beddings
contaminated with
blood or body fluid
(h) Microbiology,
Biotechnology and
other clinical
laboratory waste
Red Contaminated
Waste (Recyclable)
White (Translucent) Waste sharps
including Metals
Blue Glassware
Metallic Body
Implants
34. Brief description of arrangements for Document is attached:
handling of biomedical waste :
(i) Mode of transportation of bio-medical
waste
(ii) Details of treatment equipment (mention equipment used for waste management
only):
No of units Capacity of each unit
Incinerators
Plasma Pyrolysis
Autoclaves
Microwave
Hydroclave
Shredder
Needle tip cutter or
destroyer
Sharps encapsulation or
concrete pit
Deep burial pits
Chemical disinfection
Any other treatment
equipment
35. Declaration:
I do hereby declare that the statements made and information given above are true to
the best of my knowledge and belief and that I have not concealed any information.
I do also hereby undertake to provide any further information sought by the
prescribed authority in relation to these rules and to fulfil any conditions stipulated by
the prescribed authority.

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Date: Signature:
Place: Designation:

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