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Form-4

APPLICATION FOR AMENDMENT IN ENVIRONMENTAL CLEARANCE

(To be filled up by User Agency)

1.	Details of Project

Proposal No. : SIA/OR/MIN/296864/2023
(a) Name of the project : Proposal for Ammendement of Replenishment Study Report to EC of Kumuriguda river sand bed(KhataNo-123 & PlotNo-1414)2.70Ha. at village kumuriguda, Khondamals Tahsil, Kandhamal of Gitanjali Panigrahi
(b) Name of Company / Organisation. : GITANJALI PANIGRAHI
(c) Registered Address. : At: Ward No.-05, Santosh Marg (B.B Pada), Bhawanipatna Orissa 766001
(d) Legal Status of the Company. : Individual
(e) Joint Venture (Yes/No) : No

2.	Address for the Correspondence

(a) Name of the Applicant. : GITANJALI PANIGRAHI
(b) Designation (Owner/Partner/CEO) : No
(c) Address :-
       State : Orissa
       District : Kalahandi
       Town / Village : No
(d) Pin Code : 766001
(e) Email : gitanjalipanigrahi.kumuriguda@gmail.com
(f) Telephone no : No
(g) Fax no : No
(h) Mobile no : 9439817584
(i) Contact Person. : GITANJALI PANIGRAHI
(j) Website (if any) : No

3.	Category of the Project/Activity as per Schedule of EIA Notification,2006

(a). Major Activity. : 1(a) Mining of minerals

      Minor Activity : No
      Major Sub Activity. : No
      Minor Sub Activity : No
(b). Category : B2
      Reason for applicant at central level/state level(in case of B1 and B2 ): No
(c). Reason : No
      EAC Concerned (for category A Projects Only ): No

4.	Location of the Project

(a) Plot No/Survey No/Khasra No : Khata No-123 and Plot No.-1414 at village- Kumuriguda, Tahasil- Khondamals, district Kandhamal
(b) Village : Kumuriguda
(c) Tehsil : Phulabani
(d) District : Kandhamal
(e) State : Orissa
(f) Pin Code : 762001
(g) Bounded Latitudes (North) : Yes
        From : Degree:20, Minutes : 23, Seconds :47
        To    : Degree:20, Minutes : 24, Seconds :01
(h) Bounded Longitudes (East) : Yes
        From : Degree:84, Minutes : 12, Seconds :42
        To    : Degree:84, Minutes : 13, Seconds :4
(i) Survey of India Topo Sheet No : F45S3, F45S7

5	Details of Environmental Clearance

(a) Project Name : Proposal for Ammendement of Replenishment Study Report to EC of Kumuriguda river sand bed(KhataNo-123 & PlotNo-1414)2.70Ha. at village kumuriguda, Khondamals Tahsil, Kandhamal of Gitanjali Panigrahi
(b) MoEF&CC / SEIAA File No : SIA/OR/MIN/281018/2022
(c) Date of issue of EC : 13/07/2022 (d) Uploaded EC letter :

6	Details of Consent to Operate

(i) Whether Consent to operate obtained (Yes/No) ? : Yes (ii) Uploaded copies of all Consent to operate obtained since inception:

(iii)Date of issue : 12/09/2022
(iv)Valid Upto: 21/01/2023
(v)File No : 2750/CTO-2304/2022
(vi)Application No : 4386440 (vii)Uploaded copy of Consent to operate valid as on Date:

7	Amendment Sought for

Amendment in Configuration/ Amendments in Clearance condition/ Other (specify) : Ammendement of Replenishment study to the EC for complaince to the stipulated condition mentioned in

8	Details of Product (as per the approved EC)

Details of Products
S.no	Product / Activity (Capacity/ Area).	Quantity	Unit	Mode of Transport/ Transmission of Product
1	Sand	2700	Others	Road

9	Details of Configuration (Multiple Entries Allowed)

Details of Configurations
S.no	Plant/ Equipment/ Facility	Existing Configuration	Proposed Configuration	Final configuration after Amendment	Remarks if Any
1	Manual method of mining	6805cum mineable reserve as per approved mining pl	911.5309cum mineable reserve as per post-monsoon r	911.5309cum mineable reserve as per post-monsoon r	The reserve has been estimated from the Post-monsoon Replenishment study conducted in the month of d

10	Reasons for Amendment

Reasons for Amendment : The Replenishment study report has been proposed to be amended to the EC for compliance to the stipulated condition mentioned in the point no-9.2.

11	Any Other Amendment required

Any Other Amendment Required
S.no	Reference of Approved EC	Description as per Approved EC	Description as per Proposal.	Remarks
1	EC grant: File No-3403/SEIAA, Transfer EC Grant Letter-SIA/OR/MIN/281018/2022	2700cum upto depth of 0.5m is permitable to be ext	911.5309cum upto depth of 0.7m mineable reserve	as per post-monsoon study the reserve has been est

12	Details of EIA Consultant

Have you hired Consultant for preparing document (Yes/No) ? : No
(i)Reason for not engaging the Consultant : as it is a B2 category mine

13.	Documents to be Attached

(a) Uploaded addendum to EIA/EMP Report:

(b) Uploaded Copy of revised -Feasibility Report /Detailed Project Report (DPR) / Detailed Engineering Report / Detailed Conceptual Plan / Approved Mining Plan (in case of mining proposals):

(c) Uploaded Copy of final Layout Plan:

(d)Uploaded Cover Letter duly signed by the project proponent or authorized person:

(e)Uploaded a copy of authorization duly signed by the project proponent in support of the person making this application on behalf of the User Agency:

(f)Uploaded Additional File, If any:

Essential Details Sought

Essential Details Sought
S.no.	EDS Sought Date	EDS Sought	Letter
1.	28/01/2023	The project proponent ask to submit the earlier EC compliance with production details and also submit the replenishment study report with attaching both pre-monsoon & post-monsoon data and also as per MoEF & CC, Govt. of India guideline.

Additional Detail Sought: NIL

14.	Undertaking

(a): 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. (b)Name : GITANJALI PANIGRAHI (c)Designation: No (d)Company: GITANJALI PANIGRAHI (e)Address: At: Ward No.-05, Santosh Marg (B.B Pada), Bhawanipatna Orissa 766001