West Bengal Pollution Control Board
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Hazardous Waste Authorization

Application Form
GENERAL INFORMATION
Applicant Name:* Date Of Application:
(DD/MM/YYYY)
Place Of Application:* Name Of Unit:*
Address Of Unit :
Street/Road Name: Post Office:*
District:* Pin Code:*
Telephone: Fax:
Email: Local Body:*
Police Station:*
UNIT DETAILS
Unit Type :
Type Of The Unit:*
Authorization Required For:*
Collection
Transport
Reception
 Storage
Treatment
Disposal
Renewal Of Authorization :* Whether Generating Hazardous Waste :*
Previous Authorization No.: Type Of Waste:
Previous Authorization Date:
(DD/MM/YYYY) 		Quantity Of Waste:
 
Total Invested Capital:*
(Land+Building+Plant+Machinery-PCSCost)
 
Year Of Commencement Of Production: Industry Works:*
List and Quantum
Of Products and Byproducts
(MT/Month):		 List and Quantum
Of Raw Materials
(MT/Month):
SEWAGE AND TRADE EFFLUENT
 
Quantity and Source Of Water
  Cooling
(m3/d)		 Process
(m3/d)		 Domestic
use
(m3/d)		 Others
(m3/d)
Source For
Quantity For
Sewage and Trade Effluent Discharge
Quantum Of Discharge(m3/d): Effluent Treatment Plant Present:*
Description:  
Characteristics Of Final Effluent
Analysis Report Attached:*
 
Disposal Mode: Final Discharge Point:
Parameters Of 
Self Monitoring:		 Frequency Of
Self Monitoring:
STACK (CHIMNEY) AND VENT EMISSIONS
 
Stack/Vent Details
Number Of Stacks:* Number Of
Vents:*
Specification Of Stacks/ Vents:
Analysis Report Attached:*
HAZARDOUS WASTES
 
Hazardous Wastes And Mode Of Disposal:
Serial No.* Waste Description* Waste Category Schedule* Waste Stream Waste Type* Waste Quantity(MT/yr)* Mode of Storage* Mode of Treatment* Mode of Disposal* Disposal Quantity (MT/Year) Name Of Unit Address Of Unit
Street/ Road Name Post Office District State
1
2
3
4
5
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Hazardous Chemicals
Isolated Storage Involved:* Details (If Yes):
TREATMENT,STORAGE AND DISPOSAL FACILITY
 
Location Of Site: Name Of Waste Processing Technology:
Details Of Processing Technology:  
Waste Processed Details
Type Of Waste To Be Processed Per Day: Quantity :
 
Site Clearance From Local Authority Available:  
Utilization Program For Waste Processed:  Method Of Disposal:
Quantity Of Waste To Be Disposed Per Day: Nature Of Waste:
Composition Of Waste: Methodology and Operational Details Of Land Filling/Incineration:
Measures To Be Taken For Prevention and Control Of Environmental Pollution Including Treatment Of Leach Ate: Investment On Project:
Expected Returns: Measures To Be Taken For Safety Of Workers:
 
WASTE RECEIVED(Transportation By Waste Generator)
No Of Members :- (>0)
Members that have opted for waste transport on their own :- (>=0)
Members that have opted for waste transport by the Operator :- (>=0)

Waste Type
Waste Type
Qty(MT/Year)
Recyclable
Incinerable
Disposable
Intractable
Total

WASTE COLLECTED(Transportation byOperator)

Waste Type Qty(MT/Year)
Recyclable
Incinerable
Disposable
Intractable
Total
Total of Waste :-
Waste Treated & Disposed
Process Actual(MT/Year)Capacity(MT/Year)
Stabilization
Incineration
Landfilling (Excluding Incineration Ash)
Landfilling (Incineration Ash)
Total
Landfill Details:-

No of closed Cells :- Total Capacity(MT) :-
No. of Operating Cells :- Total Capacity(MT) :-
Disposal Details For Recyclable Waste :-

List of Enclosures
Enclosures are :
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