Ph lc 4.

1
Mu vn bn ngh xc nhn vic thc hin n bo v mi trng chi tit
(Ban hnh km theo Thng t s 01 /2012/TT-BTNMT ngy 16 thng 3 nm 2012 ca B
trng B Ti nguyn v Mi trng quy nh v lp, thm nh, ph duyt v kim tra,
xc nhn vic thc hin n bo v mi trng chi tit; lp v ng k n bo v
mi trng n gin)
(1)

CNG HO X HI CH NGHA VIT NAM

c lp - T do - Hnh phc

S:
V/v ngh kim tra, xc nhn vic
thc hin n bo v mi trng
chi tit

(a danh), ngy thng nm

Knh gi: (2)

Chng ti l: (1), Ch c s ca c s (3) (sau y gi tt l C s), c (4)
ph duyt n bo v mi trng chi tit ti Quyt nh s ngy thng nm
- a im thc hin c s:
- a ch lin h:
- in thoi: ; Fax: ; E-mail:
thc hin n bo v mi trng chi tit, gm c:
1
2

Theo quy nh ca Thng t s 01/2012/TT-BTNMT ngy 16 thng 3 nm 2012

ca B trng B Ti nguyn v Mi trng quy nh v lp, thm nh, ph duyt v
kim tra, xc nhn vic thc hin n bo v mi trng chi tit; lp v ng k n
bo v mi trng n gin, xin gi n qu (2) h s gm:
- Mt (01) bn sao quyt nh ph duyt km theo bn sao n bo v mi trng
chi tit c (4) ph duyt;
- Nm (05) bn bo co kt qu thc hin n bo v mi trng chi tit ca c
s;
- Ph lc (vi s lng bng vi s lng bn bo co kt qu thc hin n bo
v mi trng chi tit) km theo bo co kt qu thc hin n bo v mi trng chi
tit, bao gm cc bn sao ti liu sau (ty loi hnh c s m c th c mt s hoc tt c
cc ti liu ny):
+ H s bn v hon cng cc cng trnh x l v bo v mi trng (trng hp
cha c bn v hon cng, c th cung cp h s thit k k thut. Trng hp ch c h
s thit k k thut, cn nu r thc hin ng nh h s thit k k thut hay khng.
Nu c sai khc cn ch r);
+ Cc chng ch, chng nhn, cng nhn ca cc thit b x l mi trng ng b
nhp khu hoc c thng mi ha (nu c);
1/8

+ Cc phiu ly mu v kt qu o c, phn tch mu vn hnh th nghim cc

cng trnh x l cht thi;
+ Bin bn nghim thu cc cng trnh bo v mi trng hoc cc vn bn khc c
lin quan n cc cng trnh, bin php bo v mi trng;
+ Hp ng thu gom, vn chuyn, x l cht thi rn thng thng vi n v c
chc nng (i vi trng hp c s c pht sinh cht thi rn thng thng trong giai
on vn hnh v khng c cng trnh x l cht thi rn thng thng);
+ S ng k ch ngun thi cht thi nguy hi; hp ng thu gom, vn chuyn, x
l cht thi nguy hi vi n v c chc nng, km theo vn bn chng minh chc nng ca
n v (i vi trng hp c s c pht sinh cht thi nguy hi trong giai on vn
hnh v khng c cng trnh x l cht thi nguy hi);
+ Hp ng hoc bin bn tha thun v vic u ni vo h thng thu gom v x
l nc thi (i vi trng hp c s nm trong khu sn xut, kinh doanh, dch v tp
trung v c pht sinh nc thi trong giai on vn hnh);
+ Quyt nh ph duyt k hoch phng nga v ng ph s c trn du; vn bn
chng nhn iu kin v phng chy cha chy cp cho c s (i vi trng hp c
s thuc i tng phi c cc loi vn bn ny theo quy nh ca php lut).
Chng ti xin bo m v trung thc ca cc thng tin, s liu c a ra
trong cc ti liu nu trn. Nu c g sai tri, chng ti xin hon ton chu trch nhim
trc php lut ca nc Cng ho x hi ch ngha Vit Nam.
ngh qu (2) kim tra, xc nhn vic thc hin n bo v mi trng chi
tit./.
Ni nhn:
- Nh trn;
- (6)
- Lu:...

(5)
(K, ghi h tn, chc danh, ng du)

Ghi ch:
(1) Tn ch c s.
(2) Tn c quan c trch nhim kim tra, xc nhn.
(3) Tn y ca c s.
(4) C quan ph duyt n bo v mi trng chi tit.
(5) i din c thm quyn ca ch c s.
(6) Ni nhn khc (nu c).

2/8

Ph lc 4.2
Mu bo co kt qu vic thc hin n bo v mi trng chi tit
(Ban hnh km theo Thng t s 01 /2012/TT-BTNMT ngy 16 thng 3 nm 2012 ca B
trng B Ti nguyn v Mi trng quy nh v lp, thm nh, ph duyt v kim tra,
xc nhn vic thc hin n bo v mi trng chi tit; lp v ng k n bo v
mi trng n gin)
(1)
CNG HO X HI CH NGHA VIT NAM
c lp T do Hnh phc
S: /..
V/v bo co v ngh xc
(a danh), ngy thng nm
nhn hon thnh vic thc hin
n bo v mi trng chi tit
Knh gi: (2)
(1) xin bo co kt qu thc hin n bo v mi trng chi tit ca (3)
(hoc giai on ca (3)) theo k hoch xy dng v vn hnh th nghim
c ra trong n bo v mi trng chi tit, c th nh sau:
1. V tr ca (3) :

...

2. a ch v phng tin lin h ca (1) :

- a ch lin h theo bu in:
- in thoi: ; Fax: ; E-mail:
3. Kt qu vn hnh th nghim
3.1. Cc cng trnh x l ton phn
3.1.1. Cng trnh xy dng tng th
3.1.2. Cng trnh xy dng theo tng giai on/m-un (nu c)
3.2. Cc cng trnh x l trung gian (nu c)
3.2.1. Cng trnh xy dng tng th
3.2.2. Cng trnh xy dng theo tng giai on/m-un (nu c)
Yu cu:
1. i vi vic th nghim x l kh thi, nc thi:
- Ch dn r: Tn v a ch ca n v thc hin vic o c, ly mu, phn tch
mu; phng php o c, ly mu, phn tch mu; thit b o c, ly mu, phn tch
mu trong cc ln th nghim.
- Kt qu th nghim ca tng cng trnh (ton phn hoc trung gian) c trnh
by theo bng sau:
Thng s

n v tnh

Trc khi x
l

Sau khi x l

Theo QCVN

Th nghim ln 1: Ngy thng nm ; Tng lng/Lu lng .

A
B
3/8

.
Th nghim ln 2: Ngy thng nm ; Tng lng/Lu lng .
A
B
.
Th nghim ln 3: Ngy thng nm ; Tng lng/Lu lng .
A
B
.
2. i vi vic th nghim x l cht thi rn thng thng, cht thi nguy hi:
- Trng hp t x l: M t quy trnh qun l (thu gom, vn chuyn, lu gi,
x l); bin php, phng tin, tin nghi s dng trong tng cng on ca quy trnh
qun l.
- Trng hp thu x l: M t cc bin php, phng tin, tin nghi thu gom
v lu gi tm thi; tn v a ch ca n v x l thu; bin php, phng tin thu
gom v vn chuyn ca n v x l thu; tn sut thu gom ca n v x l thu.
4. Nhng thay i so vi k hoch ra trong n bo v mi trng chi tit
(nu c)
5. nh gi kt qu th nghim
- nh gi v tin cy, mc t c v tnh n nh ca kt qu th
nghim x l kh thi, x l nc thi.
- nh gi v mc tun th quy nh ca cc bin php qun l cht thi rn
thng thng v cht thi nguy hi.
6. H s km theo bo co
Chng ti xin gi nhng h s, ti liu c lin quan c ng thnh tp km
theo bo co ny.
7. Cam kt v ngh
Chng ti cam kt rng nhng thng tin, s liu nu trn l ng s thc; nu c
g sai tri, s phi hon ton chu trch nhim trc php lut.
ngh (2) kim tra v xc nhn chng ti a cng trnh vo vn hnh
chnh thc./.
Ni nhn:
- Nh trn;
- (5)
- Lu:

(4)
(K, ghi h tn, chc danh, ng du)

Ghi ch:
(1) Tn c quan/doanh nghip ch c s.
(2) Tn c quan c trch nhim cp giy xc nhn hon thnh.
(3) Tn y ca c s.
(4) i din c thm quyn ca c quan/doanh nghip ch c s.
(5) Ni nhn khc (nu c).
4/8

Ph lc 4.3
Mu bo co kt qu vic thc hin n bo v mi trng chi tit (i vi c s quy
nh ti im e khon 1 iu 3 Thng t ny v khai thc khong sn)
(Ban hnh km theo Thng t s 01 /2012/TT-BTNMT ngy 16 thng 3 nm 2012 ca B trng
B Ti nguyn v Mi trng quy nh v lp, thm nh, ph duyt v kim tra, xc nhn vic
thc hin n bo v mi trng chi tit; lp v ng k n bo v mi trng n gin)
(1)

CNG HO X HI CH NGHA VIT NAM

c lp T do Hnh phc

S: /..
V/v bo co kt qu hon thnh
hng mc cng trnh qun l, x
l cht thi v cng trnh lin
quan n bo v mi trng

(a danh), ngy thng nm

Knh gi: (2)

(1) xin bo co kt qu hon thnh xy dng cc cng trnh qun l, x l cht
thi v cng trnh c lin quan n bo v mi trng phc v cho giai on khai thc khong
sn ca (3) theo k hoch v ni dung c ra trong n bo v mi trng chi
tit, c th nh sau:
1. V tr ca (3) : ...
2. a ch v phng tin lin h ca (1) :
- a ch lin h theo bu in:
- in thoi: ; Fax: ; E-mail:
3. Hng mc cng trnh xy dng xong
TT

Hng mc

1
2
3
4
5
6
1
2

M t
3
Cng trnh qun l, x l cht thi

Cng trnh x l nc
thi
Cng trnh x l kh thi
Ni lu gi, trung
chuyn cht thi rn
thng thng
Ni lu gi, trung
chuyn cht thi nguy
hi
Cng trnh chng n,
rung
Cng trnh khc ..
..
Cng trnh c lin quan n bo v mi trng
ng giao thng ni b
m
ng giao thng ngoi
5/8

3
4
5
6
7
8
9
10

m do c s t xy dng
H thng thot nc m
H thng bi thi trong,
bi thi ngoi
Kho thuc n
Kho ha cht
H thng dung dch
khoan (trong khai thc
du kh, nc ngm)
H thng chng phun,
chng pht (trong khai
thc du kh)
H thng ng ph s c
trn du (trong khai thc
du kh)
Hng mc khc ..

Yu cu: Phi c s tng mt bng ch dn v tr tng hng mc cng trnh vi ch gii r

rng.
4. H s km theo bo co
Chng ti xin gi nhng h s, ti liu c lin quan c ng thnh tp km theo bo
co ny.
5. Cam kt v ngh
Chng ti cam kt rng nhng thng tin, s liu nu trn l ng s thc; nu c g sai
tri, s phi hon ton chu trch nhim trc php lut.
ngh (2) kim tra v xc nhn chng ti a cng trnh vo hot ng./.
(4)
Ni nhn:
- Nh trn;
- (5)
- Lu:

(K, ghi h tn, chc danh, ng du)

Ghi ch:
(1) Tn c quan/doanh nghip ch c s.
(2) Tn c quan c trch nhim cp giy xc nhn hon thnh.
(3) Tn y ca c s.
(4) i din c thm quyn ca c quan/doanh nghip ch c s.
(5) Ni nhn khc (nu c).

6/8

Ph lc 4.4
Mu bo co kt qu vic thc hin n bo v mi trng chi tit (i vi c s quy
nh ti im e khon 1 iu 3 Thng t ny c h cha nc)
(Ban hnh km theo Thng t s 01 /2012/TT-BTNMT ngy 16 thng 3 nm 2012 ca B trng
B Ti nguyn v Mi trng quy nh v lp, thm nh, ph duyt v kim tra, xc nhn vic
thc hin n bo v mi trng chi tit; lp v ng k n bo v mi trng n gin)
(1)

CNG HO X HI CH NGHA VIT NAM

c lp T do Hnh phc

S: /..
V/v bo co v vic thu dn
lng h v xy dng cc bin
php bo v mi trng

(a danh), ngy thng nm

Knh gi: (2)

(1) xin bo co kt qu hon thnh vic thu dn lng h v xy dng bin php
bo v mi trng (nu c) ca (3) theo k hoch v ni dung c ra trong n
bo v mi trng chi tit, c th nh sau:
1. V tr ca (3) : ...
2. a ch v phng tin lin h ca (1) :
- a ch lin h theo bu in:
- in thoi: ; Fax: ; E-mail:
3. Kt qu thu dn lng h
TT
Hng mc thu dn

1
1
2
3
4

5
6

2
Thm thc vt (din
tch, sinh khi, cy c
g)
Nh
M m
Cng trnh vn ha,
tn gio, tn ngng
(tn c th tng cng
trnh)
Khong sn khai thc
tn thu (tn c th
tng loi)
Cng trnh sn xut,
kinh doanh, dch v
(tn c th tng cng

n
v
tnh

Khi
lng,
s
lng

Hnh thc,
cch thc tin
hnh

Mc
hon thnh
so vi k
hoch hoc
yu cu t
ra

Ghi ch

7/8

trnh)
Hng mc khc

4. Nhng hng mc khng th thu dn c (nu c)

- Tn hng mc khng th thu dn c
- L do khng th thu dn c
- Bin php x l hoc kin ngh bin php x l
5. Cc bin php bo v mi trng (nu c)
6. H s km theo bo co
Chng ti xin gi nhng h s, ti liu c lin quan c ng thnh tp km theo bo
co ny.
7. Cam kt v ngh
Chng ti cam kt rng nhng thng tin, s liu nu trn l ng s thc; nu c g sai
tri, s phi hon ton chu trch nhim trc php lut.
ngh (2) kim tra v xc nhn chng ti a cng trnh h cha vo tch
nc./.
(4)
Ni nhn:
- Nh trn;
- (5)
- Lu:

(K, ghi h tn, chc danh, ng du)

Ghi ch:
(1) Tn c quan/doanh nghip ch c s.
(2) Tn c quan c trch nhim cp giy xc nhn hon thnh.
(3) Tn y ca c s.
(4) i din c thm quyn ca c quan/doanh nghip ch c s.
(5) Ni nhn khc (nu c).

8/8