Mu s A.

4
CNG HA X HI CH NGHA VIT NAM
c lp T do - Hnh phc
----------------------------------N NGH CP GIY PHP
X NC THI VO NGUN NC
Knh gi: S Ti nguyn Mi trng v Nh t H Ni (1)
1- T chc/c nhn ngh cp php:
1.1. Tn t chc/c nhn:(2)
1.2. a ch:.(3)
1.3. in thoi:.. Fax:. Email.
1.4. Hot ng x nc thi vo ngun nc:..(4)
2- L do ngh cp php:

3- Ni dung ngh cp php:

3.1. Ngun nc tip nhn nc thi:(5)
3.2. V tr ni x nc thi:
Thn/xm.x/phng..huyn/qun
Ta v tr x thi(6)
3.3. Phng thc x nc thi:
- M t phng thc x nc thi:.(7)
- M t ch x nc thi:(8)
- Lu lng x trung bnh: m3/ngym;
m3/h
3
- Lu lng x ln nht:
m /ngym;
m3/h
3.4. Cht lng nc thi:(9)
3.5. Thi gian x nc thi vo ngun nc:.
4- Giy t ti liu np km theo n ny gm c: Vn bn bo co v cc cng trnh
thm d, khai thc nc, x nc thi vo ngun nc (nu c) ca n v trn a bn
thnh ph;..........................(10)
(Tn t chc/c nhn ngh cp php)gi mt (01) b h s ti S Ti nguyn
Mi trng v Nh t H Ni
ngh S Ti nguyn Mi trng v Nh t H Ni xem xt cp giy php x
nc thi vo ngun nc cho (tn t chc/c nhn ngh cp php).
(T chc/c nhn ngh cp php) cam kt chp hnh ng ni dung quy nh
trong giy php v quy nh ca php lut c lin quan./.
..ngy.thng..nm
Xc nhn ca UBND x, phng
T chc, c nhn ngh cp php
(i vi t chc/c nhn khng c t cch K, ghi r h tn, (ng du nu c)
php nhn v con du)

Hng dn vit n
(1) Tn c quan cp php:
(2) Tn t chc, c nhn ngh cp php: i vi c nhn ghi r h, tn, s Chng
minh nhn dn, ngy v ni cp, c quan cp; i vi t chc th ghi tn t chc,
ngy thng, nm thnh lp, s v ngy c quan k quyt nh thnh lp hoc s
giy ng k kinh doanh, giy php u t ca c quan nh nc c thm quyn.
(3) Tr s ca t chc hoc ni c tr ca c nhn ngh cp php.
(4) Phn ny ch p dng vi trng hp c hot ng x nc thi v ngun nc
trc thi im xin cp php: cn nu r c s c cng trnh x l nc thi
hay cha c cng trnh x l nc thi; nu c cng trnh x l nc thi th phi
nu r nm bt u vn hnh cng trnh.
(5) Ghi r tn song, sui, rch, vng bin ven b, h, m, ao ngh c php x
nc thi vo ngun nc.
(6) Ghi r ta v tr ca x nc theo h ta VN2000
(7) Nu r x nc thi theo phng thc bm, t chy, x ngm, x mt, x ven b,
x gia h, sng
(8) Nu r chu k x nc thi, thi gian x nc thi ca mt chu k.
(9) Ghi r tn Tiu chun Vit Nam m cht lng nc thi t c (vi trng
hp ang c hot ng x nc thi vo ngun nc) hoc s t c (vi
trng hp cha x nc thi vo ngun nc). Trong trng hp ang c hot
ng x nc thi vo ngun nc m cht lng nc thi cha t Tiu chun
Vit Nam hin hnh th phi lit k thng s v nng cc cht nhim cha
t Tiu chun Vit Nam v cam kt thi hn x l cht lng nc thi t Tiu
chun Vit Nam hin hnh. Trc mt phi x l t ti no.
(10) Ghi r cc giy t, ti liu km theo h s.