Application to obtain ENVIRONMENTAL CLEARANCE FORM-1 IN INDIA

FORM 1

(I)                                     Basic Information

Sl.No.	Item	Details
	Name of the project/s
	S.No. in the schedule
	Proposed capacity /area/length/tonnage to be handled/command area/lease area/number of wells to be drilled.
	New/Expansion/Modernization
	Existing Capacity/Area etc.
	Category of Project i.e. ‘A’ or ‘B’
	Does it attract the general condition? If yes, please specify.
	Does it attract the specific condition? If yes, please specify.
	Location Plot/Survey/Khasra No. Village Tehsil District State
	Nearest railway station/airport along with distance in kms.
	Nearest Town, city, district Headquarters along with distance in kms.
	Village Panchayats, Zilla Parishad, Municipal Corporation, Local body (complete postal addresses with telephone nos. to be given)
	Name of the applicant
	Registered Address
	Address for correspondence: Name Designation (Owner/Partner /CEO) Pin code E-mail Telephone No. Fax No.
	Details of Alternative Sites examined, if any. Location of these sites should be shown on a topo sheet.	Village-District-State 1 2 3
	Interlinked Projects
	Whether separate application of interlinked project has been submitted?
	If yes, date of submission
	If no, reason
	Whether the proposal involves approval/clearance under: if yes, details of the same and their status to be given. i.                The Forest (Conservation) Act, 1980? ii.              The Wildlife (Protection) Act, 1972? iii.             The C.R.Z. Notification, 1991?

22.	Whether there is any Government Order/Policy relevant /relating to the site?
23.	Forest land involved (hectares)
24.	Whether there is any litigation pending against the project and/or land in which the project is propose to be set up? a)      Name of the Court b)      Case No. c)      Orders/directions of the Court, if any and its relevance with the proposed project.

(II)                   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 thereof (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)
1.2	Clearance of existing land, vegetation and buildings?
1.3	Creation of new land uses?
1.4	Pre-construction investigations e.g. bore houses, soil testing?
1.5	Construction works?
1.6	Demolition works?
1.7	Temporary sites used for construction works or       housing of construction workers?
1.8	Above ground buildings, structures or       earthworks including linear structures, cut and   fill or excavations
1.9	Underground works including mining or     tunneling?
1.10	Reclamation works?
1.11	Dredging?
1.12	Offshore structures?

1.13	Production and manufacturing processes?
1.14	Facilities for storage of goods or materials?
1.15	Facilities for treatment or disposal of solid waste or liquid effluents?
1.16	Facilities for long term housing of operational        workers?
1.17	New road, rail or sea traffic during construction or operation?
1.18	New road, rail, air waterborne or other transport infrastructure including new or altered routes and stations, ports, airports etc?
1.19	Closure or diversion of existing transport routes or infrastructure leading to changes in traffic         movements?
1.20	New or diverted transmission lines or pipelines?
1.21	Impoundment, damming, culverting, realignment or other changes to the hydrology   of watercourses or aquifers?
1.22	Stream crossings?
1.23	Abstraction or transfers of water form ground or surface waters?
1.24	Changes in water bodies or the land surface affecting drainage or run-off?
1.25	Transport of personnel or materials for construction, operation or decommissioning?
1.26	Long-term dismantling or decommissioning or restoration works?
1.27	Ongoing activity during decommissioning which could have an impact on the environment?
1.28	Influx of people to an area in either temporarily or permanently?
1.29	Introduction of alien species?
1.30	Loss of native species or genetic diversity?
1.31	Any other actions?

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)
2.2	Water (expected source & competing users) unit: KLD
2.3	Minerals (MT)
2.4	Construction material – stone, aggregates, sand / soil (expected source – MT)
2.5	Forests and timber (source – MT)
2.6	Energy including electricity and fuels (source, competing users) Unit: fuel (MT), energy (MW)
2.7	Any other natural resources (use appropriate standard units)

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)
3.2	Changes in occurrence of disease or affect disease vectors (e.g. insect or water borne diseases)
3.3	Affect the welfare of people e.g. by changing living conditions?
3.4	Vulnerable groups of people who could be affected by the project e.g. hospital patients, children, the elderly etc.,
3.5	Any other causes

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
4.2	Municipal waste (domestic and or commercial        wastes)
4.3	Hazardous wastes (as per Hazardous Waste        Management Rules)
4.4	Other industrial process wastes
4.5	Surplus product
4.6	Sewage sludge or other sludge from effluent        treatment
4.7	Construction or demolition wastes
4.8	Redundant machinery or equipment
4.9	Contaminated soils or other materials
4.10	Agricultural wastes
4.11	Other solid wastes

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
5.2	Emissions from production processes
5.3	Emissions from materials handling including   storage or transport
5.4	Emissions from construction activities including plant and equipment
5.5	Dust or odours from handling of materials including construction materials, sewage and  waste
5.6	Emissions from incineration of waste
5.7	Emissions from burning of waste in open air (e.g. slash materials, construction debris)
5.8	Emissions from any other sources

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 with source of information data
6.1	From operation of equipment e.g. engines, ventilation plant, crushers
6.2	From industrial or similar processes
6.3	From construction or demolition
6.4	From blasting or piling
6.5	From construction or operational traffic
6.6	From lighting or cooling systems
6.7	From any other sources

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
7.2	From discharge of sewage or other effluents to water or the land (expected mode and place of       discharge)

7.3	By deposition of pollutants emitted to air into the land or into water
7.4	From any other sources
7.5	Is there a risk of long term build up of pollutants in the environment from these      sources?

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
8.2	From any other causes
8.3	Could the project be affected by natural disasters causing environmental damage (e.g.     floods, earthquakes, landslides, cloudburst etc)?

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.       lities, 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

9.2	Lead to after-use of the site, which could havean impact on the environment
9.3	Set a precedent for later developments
9.4	Have cumulative effects due to proximity to other existing or planned projects with similar    effects

(III)          Environmental Sensitivity

                       

S.No.	Areas	Name/ Identity	Aerial distance (within 15 km.) Proposed project location boundary
1	Areas protected under international conventions,   national or local legislation for their ecological,    landscape, cultural or other related value
2	Areas which are important or sensitive for ecological reasons - Wetlands, watercourses or other water bodies, coastal zone, biospheres, mountains, forests
3	Areas used by protected, important or sensitive   species of flora or fauna for breeding, nesting, foraging, resting, over wintering, migration
4	Inland, coastal, marine or underground waters
5	State, National boundaries
6	Routes or facilities used by the public for access     to recreation or other tourist, pilgrim areas
7	Defence installations
8	Densely populated or built-up area
9	Areas occupied by sensitive man-made land uses    (hospitals, schools, places of worship, community facilities)
10	Areas containing important, high quality or scarce resources  (ground water resources, surface resources, forestry, agriculture, fisheries, tourism, minerals)
11	Areas already subjected to pollution or      environmental damage. (those where existing legal environmental standards     are exceeded)
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)

(IV).Proposed Terms of Reference for EIA studies:

“I hereby given undertaking that the data and information given in the application and enclosures are true to the best of my knowledge and belief and I am aware that if any part of the data and information submitted is found to be false or misleading at any stage, the project will be rejected and clearance give, if any to the project will be revoked at our risk and cost.

Date:  _______________

Place: ______________                                                

Signature of the applicant with Name and Full Address

       (Project Proponent /Authorised Signatory)

Note:

1.      The projects involving clearance under Coastal Regulation Zone Notification, 1991 shall submit with the application a C.R.Z map duly demarcated by one of the authorized agencies, showing the project activities, w.r.t. C.R.Z (at the stage of TOR) and the recommendations of the State Coastal Zone Management Authority (at the state of EC). Simultaneous action shall also be taken to obtain the requisite clearance under the provisions of the C.R.Z Notification, 1991 for the activities to be located in the CRZ.

2.      The projects to be located within 10 km of the National Parks, Sanctuaries, Biosphere Reserves, Migratory Corridors of Wild Animals, the project proponent shall submit the map duly authenticated by Chief Wildlife Warden showing these features vis-à-vis the project location and the recommendations or comments of the Chief Wildlife Warden thereon (at the state of EC).”

3.      All correspondence with the Ministry of Environment & Forests including submission of application for TOS/Environmental Clearance, subsequent clarifications, as may be required from time to time, participation the EAC Meeting on behalf of the project proponent shall be made by the authorized signatory only. The authorized signatory should also submit a document in support of his claim of being an authorized signatory for the specific project.”