Form-1
APPLICATION FOR PRIOR ENVIRONMENTAL CLEARANCE
1. Basic Informations
Project Name testing5fapi Company/Organisation Name Agency_Name
Registered Address , , , Delhi 0 Legal Status of the Company State PSU
2.
Address for the correspondence:
(a)Name of the Applicant Kali kumar mandal
(b)Designation (Owner/ Partner/ CEO) programmer
(c)Address 55 56 rajat vihar,khora noida,Gandhi Nagar,East,Delhi-123456
(d)Pin code 123456
(e)E-mail rupeshyadav12@gmail.com
(f)Telephone No. 1234578
(g)Fax No. 11123456
(h)Copy of documents in support of the competence/authority of the person making this application to make application on behalf of the User Agency . Annexure-Uploaded Copy of documents in support of the competence/authority
3.
Category of the Project/Activity as per Schedule of EIA Notification,2006:
(a)Major Project/Activity5(f)-API
(b)Minor Project/ActivityNIL
(c)Category B2
(d)Proposal Number IA/GJ/IND2/221389/2021
(e)Master Proposal Number(Single Window) SW/221387/2021
(f)EAC concerned (for category A Projects only) Industrial Projects - 2
(g)Project Type(New/Expansion/Modernization) Fresh EC
4.
(a)Number of States in which Project will be Executed 1
(b)Main State of the project Gujarat
Details of State of the project
S. No. State Name District Name Tehsil Name Village Name
NIL
5.
Details of Public Consultation:
(a)Whether the Project Exempted from Public Hearing?Yes
(c)Reason -1
(d)Supporting Document Copy of Supporting Document

Activity
1. Construction, operation or decommissioning of the Project involving actions, which will cause physical changes in the locality (topography, land use, changes in water bodies, etc.)
S.No Information/Checklist confirmation Yes/No Details there of (with approximate quantities/rates, wherever possible) with source of information data
1.1 Permanent or temporary change in land use, land cover or topography including increase in intensity of land use (with respect to local land use plan) Yes y
1.2 Clearance of existing land, vegetation and buildings? Yes y8
1.3 Creation of new land uses? Yes y8
1.4 Pre-construction investigations e.g. bore houses, soil testing? Yes y8
1.5 Construction works? Yes yu
1.6 Demolition works? Yes 8
1.7 Temporary sites used for construction works or housing of construction workers? Yes 8
1.8 Above ground buildings, structures or earthworks including linear structures,cut and fill or excavations and fill or excavations Yes 8
1.9 Underground works including mining or tunneling? Yes 8
1.10 Reclamation works? Yes 8
1.11 Dredging? Yes 8
1.12 Offshore structures? Yes 8
1.13 Production and manufacturing processes? Yes 8
1.14 Facilities for storage of goods or materials? Yes 8
1.15 Facilities for treatment or disposal of solid waste or liquid effluents? Yes 8
1.16 Facilities for long term housing of operational workers? Yes 8
1.17 New road, rail or sea traffic during construction or operation? Yes 8
1.18 New road, rail, air water borne or other transport infrastructure including new or altered routes and stations, ports, airports etc? Yes 8
1.19 Closure or diversion of existing transport routes or infrastructure leading to changes in traffic movements? Yes 8
1.20 New or diverted transmission lines or pipelines? Yes 8
1.21 Impoundment, damming, culverting, realignment or other changes to the hydrology of watercourses or aquifers? Yes 8
1.22 Stream crossings? Yes 8
1.23 Abstraction or transfers of water from ground or surface waters? Yes 8
1.24 Changes in water bodies or the land surface affecting drainage or run-off? Yes 7
1.25 Transport of personnel or materials for construction, operation or decommissioning? Yes 8
1.26 Long-term dismantling or decommissioning or restoration works? Yes 7
1.27 Ongoing activity during decommissioning which could have an impact on the environment? Yes 7
1.28 Influx of people to an area in either temporarily or permanently? Yes 7
1.29 Introduction of alien species? Yes 7
1.30 Loss of native species or genetic diversity? Yes 7
1.31 Any other actions? Yes 7
2 Use of Natural resources for construction or operation of the Project (such as land, water, materials or energy, especially any resources which are non-renewable or in short supply):
S.No Information/Checklist confirmation Yes/No Details thereof (with approximate quantities/rates, wherever possible) with source of information data
2.1 Land especially undeveloped or agricultural land (ha) No n
2.2 Water (expected source & competing users) unit: KLD No n9
2.3 Minerals (MT) No n9
2.4 Construction material – stone, aggregates, sand / soil (expected source – MT) No n9
2.5 Forests and timber (source – MT) No n99
2.6 Energy including electricity and fuels (source, competing users) Unit: fuel (MT),energy (MW) No 9
2.7 Any other natural resources (use appropriate standard units) No 9
3 Use, storage, transport, handling or production of substances or materials, which could be harmful to human health or the environment or raise concerns about actual or perceived risks to human health
S.No Information/Checklist confirmation Yes/No Details thereof (with approximate quantities/rates, wherever possible) with source of information data
3.1 Use of substances or materials, which are hazardous (as per MSIHC rules) to human health or the environment (flora, fauna, and water supplies Yes 9
3.2 Changes in occurrence of disease or affect disease vectors (e.g. insect or water borne diseases) No 9
3.3 Affect the welfare of people e.g. by changing living conditions? No 90
3.4 Vulnerable groups of people who could be affected by the project e.g. hospital patients, children, the elderly etc. No 9
3.5 Any other causes Yes 7
4 Production of solid wastes during construction or operation or decommissioning (MT/month)
S.No Information/Checklist confirmation Yes/No Details thereof (with approximate quantities/rates, wherever possible) with source of information data
4.1 Spoil, overburden or mine wastes Yes 8
4.2 Municipal waste (domestic and or commercial wastes) Yes 8
4.3 Hazardous wastes (as per Hazardous Waste Management Rules) Yes 8
4.4 Other industrial process wastes Yes 8
4.5 Surplus product Yes 8
4.6 Sewage sludge or other sludge from effluent treatment Yes 8
4.7 Construction or demolition wastes No 8
4.8 Redundant machinery or equipment No 8
4.9 Contaminated soils or other materials No 9
4.10 Agricultural wastes No y7
4.11 Other solid wastes Yes 7
5 Release of pollutants or any hazardous, toxic or noxious substances to air(Kg/hr)
S.No Information/Checklist confirmation Yes/No Details thereof (with approximate quantities/rates, wherever possible) with source of information data
5.1 Emissions from combustion of fossil fuels from stationary or mobile sources No n
5.2 Emissions from production processes Yes n8
5.3 Emissions from materials handling including storage or transport Yes n7
5.4 Emissions from construction activities including plant and equipment Yes 7
5.5 Dust or odours from handling of materials including construction materials, sewage and waste Yes 7
5.6 Emissions from incineration of waste Yes 7y
5.7 Emissions from burning of waste in open air (e.g. slash materials, construction debris) Yes yy
5.8 Emissions from any other sources No y
6 Generation of Noise and Vibration, and Emissions of Light and Heat:
S.No Information/Checklist confirmation Yes/No Details thereof (with approximate quantities/rates, wherever possible) with source of information data
6.1 From operation of equipment e.g. engines, ventilation plant, crushers Yes 7
6.2 From industrial or similar processes Yes 7
6.3 From construction or demolition Yes 7
6.4 From blasting or piling Yes 7
6.5 From construction or operational traffic Yes 7
6.6 From lighting or cooling systems Yes 7
6.7 From any other sources Yes 7
7 Risks of contamination of land or water from releases of pollutants into the ground or into sewers, surface waters, groundwater, coastal waters or the sea:
S.No Information/Checklist confirmation Yes/No Details thereof (with approximate quantities/rates, wherever possible) with source of information data
7.1 From handling, storage, use or spillage of hazardous materials No 8
7.2 From discharge of sewage or other effluents to water or the land (expected mode and place of discharge) No 8
7.3 By deposition of pollutants emitted to air into the land or into water No 9
7.4 From any other sources No 9
7.5 Is there a risk of long term build up of pollutants in the environment from these sources? No 9
8 Risk of accidents during construction or operation of the Project, which could affect human health or the environment
S.No Information/Checklist confirmation Yes/No Details thereof (with approximate quantities/rates, wherever possible) with source of information data
8.1 From explosions, spillages, fires etc from storage, handling, use or production of hazardous substances Yes 7
8.2 From any other causes Yes 7
8.3 Could the project be affected by natural disasters causing environmental damage (e.g. floods, earthquakes, landslides, cloudburst etc)? Yes 7
9 Factors which should be considered (such as consequential development) which could lead to environmental effects or the potential for cumulative impacts with other existing or planned activities in the locality
S.No Information/Checklist confirmation Yes/No Details thereof (with approximate quantities/rates, wherever possible) with source of information data
9.1 Lead to development of supporting utilities, ancillary development or development stimulated   by the project which could have impact on the environment e.g.:
  • Supporting infrastructure (roads, power supply,waste or waste water treatment, etc.)
  • housing development
  • extractive industries
  • supply industries
  • Other
 Yes 8
9.2 Lead to after-use of the site, which could have an impact on the environment Yes 8
9.3 Set a precedent for later developments Yes 8
9.4 Have cumulative effects due to proximity to other existing or planned projects with similar effects Yes 8
(III) Environmental Sensitivity
S.No Areas Name/Identity Aerial distance (within 15km.) Proposed project location boundary
1 Areas protected under international conventions, national or local legislation for  their ecological, landscape, cultural or other related value
 No 8
2 Areas which are important or sensitive for ecological reasons - Wetlands, watercourses or other water bodies, coastal zone, biospheres, mountains, forests No 8n
3 Areas used by protected, important or sensitive species of flora or fauna for breeding, nesting, foraging, resting, over wintering, migration Yes n8
4 Inland, coastal, marine or underground waters Yes n8
5 State, National boundaries Yes n
6 Routes or facilities used by the public for access to recreation or other tourist, pilgrim areas Yes 7n
7 Defence installations Yes 7
8 Densely populated or built-up area Yes 7
9 Areas occupied by sensitive man-made land uses (hospitals, schools, places of worship, community facilities) Yes 7
10 Areas containing important, high quality or scarce resources.(ground water resources,surface resources,forestry,agriculture,fisheries,tourism,minerals) Yes 7
11 Areas already subjected to pollution or environmental damage.(those where existing legal environmental standards are exceeded) Yes 7
12 Areas susceptible to natural hazard which could cause the project to present environmental problems (earthquakes, subsidence, landslides, erosion, flooding or extreme or adverse climatic conditions) similar effects Yes 7
Document to be attached
1. Upload a copy of PFR Uploaded a copy of PFR.
2. Upload a copy of EMP Uploaded a copy of EMP.
3. Upload Scanned copy of covering letter. Uploaded Scanned copy of covering letter..
4. Upload Additional attached if any(Single PDF) Uploaded Additional attached if any(Single PDF).
5. Whether it is a violation case and application is being submitted under Notification No. S.O.804(E) dated 14.03.2017 ? No
           Essential Details Sought
S. No.EDS Sought DateEDS SoughtLetter
NO Record
Undertaking
I hereby give undertaking that the data and information given in the application and enclosures are true to be best of my knowledge and belief. And I am aware that if any part of the data and information found to be false or misleading at any stage, the project will be rejected and clearance given, if any to the project will be revoked at our risk and cost. In addition to above, I hereby give undertaking that no activity/ construction/ expansion has since been taken up.
Name of ApplicantKali kumar mandal
Designationprogrammer
Name of Company (Applicant Name should not be given here)Kali Mandal
AddressDelhi
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