The Water (Prevention and Control of Pollution) Rules, 1975 - Form XIII

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Application for consent for establishing or taking any steps for establishment of Industry operation process or any treatment disposal system for discharge, continuation of discharge under section 25 or section 26 of the Water (Prevention and Control of Pollution) Act, 1974.

(See Rule 32)



The Member Secretary,
Central Pollution Control Board.


I/We hereby apply for Consent/Renewal of Consent under section 25 of the Water (Prevention and Control of Pollution) Act, 1974 (6 of 1974) for establishing or taking any steps for establishment of Industry/operation process or ally treatment/disposal system to bring into use any new/altered outlet for discharge of *sewage/trade effluent* to continue to discharge* sewage/trade effluent* from land/premises owned by ____________________.

The other relevant details are below:-
I. Full Name of the applicant __________________________
2. Nationality of the applicant __________________________

(a) Individual
(b) Proprietory concern
(c) Partnership firm
(whether registered or unregistered)
(d) Joint family concern
(e) Private Limited Company
(f) Public Limited Company
(g) Govem1nc11l Company

(1) State Government
(2) Central Government
(3) Union Territory

(h) Foreign Company
(if a foreign company, the details of registration, incorporation, etc.).
(i) Any other Association or Body

4. Name, Address and Telephone Nos. of Applicant.

(the full list of individuals partners persons Chairman (full-time or part-time Managing Directors, Managing Partners Directors (Full time or part-time) other kinds of office bearers are to be furnished with their period of tenure in the respective office with telephone Nos. and address).

5. Address of the Industry:

(Survey No. Khasra No. location as per the revenue records Village Firka Tehsil District. Police Station or SHO jurisdiction of the First-Class Magistrate).

6. Details of commissionings etc.:-

(a) Approximate date of proposed commissioning of work.

(b) Expected date of production:

7. Total number of employee expected to employed.

8. Details of licence is any obtained under the provisions of Industrial Development Regulations Act 1951.

9. Name of the person authorised to sign this form (the original authorisation except in the case of individual proprietory concern is to be enclosed).

10. (a) attach the list of raw materials and chemicals used per month.

(b) Licence Annual Capacity of the Factory/Industry.

11. State daily quantity of water in kilolitres utilised and its source (domestic/industrial process boiler Cooling others).

12. (a) State the daily maximum quantity of effluents quantity and mode of disposal (sewer or drains or river). Also attach analysis report of the effluents. Type of effluent quantity in kilolitres Mode of disposal.

(i) Domestic

(ii) Industrial.

(b) Quality of effluent currently being the discharged or expected to be discharged.

(c) What monitoring arrangement is currently there or proposed.

13. Slate whether you have any treatment plant for industrial? domestic or combined effluents.


If yes attach the description of the process of treatment in brief. Attach information on the quality of treated effluent vis-a-vis the standards.

14. State details of sold wastes generated in the process or during waste treatment.

Description ............. Quantity ............. Method ............. Method of disposal

15. I/We further declare that the information furnished above is correct to the best of my/our knowledge.

16. I/We hereby submit that in case of change either of the point of discharge or the quantity of discharge or its quality a fresh application for CONSENT shall be made and until such CONSENT is granted no change shall be made.

17. I/We hereby agree to submit to the Central Board an application for renewal of consent one month in advance of the date of expiry of the consented period for outlet/discharge if to be continued thereafter.

18. I/We, undertake to furnish any other information within one month or its being called by the Central Board.

I9. I/We, enclose herewith cash receipt No./bank draft No. ___________ dated _______ for Rs. __________________ Rupee ___________________________________ ) in favour of the Central Pollution Control Board, New Delhi, as fees payable under section 25 of the Act.

Yours faithfully,
signature of the applicant

Note: * Strike out which is not relevant.

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