PH LC 3.

6
MU GIY XC NHN HON THNH CNG TRNH BO V
MI TRNG PHC V GIAI ON VN HNH CA D N
(Ban hnh km theo Thng t s 27/2015/TT-BTNMT ngy 29 thng 5 nm 2015
ca B trng B Ti nguyn v Mi trng v nh gi mi trng chin lc,
nh gi tc ng mi trng v k hoch bo v mi trng)

(1) CNG HA X HI CH NGHA VIT NAM

------- c lp - T do - Hnh phc
---------------
S: (a danh), ngy ... thng ... nm ...

GIY XC NHN
HON THNH CNG TRNH BO V MI TRNG
ca D n (2)
(3) xc nhn:
I. Thng tin chung v d n/c s:
Tn ch d n:
a ch vn phng:
a im hot ng:
in thoi: Fax:
Ti khon s: . ti
Giy chng nhn ng k kinh doanh s Ngy cp: . Ni cp:.
Quyt nh ph duyt bo co nh gi tc ng mi trng s
II. Ni dung xc nhn;
Xc nhn hon thnh cng trnh bo v mi trng phc v giai on vn
hnh ca D n (2) (ti Ph lc km theo).
III. Trch nhim ca ch d n:
Tun th cc quy nh ca php lut v bo v mi trng; thng xuyn vn
hnh v lp nht k vn hnh cc cng trnh bo v mi trng nu ti Mc
.. ca Ph lc km theo Giy xc nhn ny; thc hin ch bo co v
 bo v mi trng v chng trnh gim st mi trng theo quy nh ca
php lut.
IV. T chc thc hin:
Giy xc nhn ny l cn c ch d n a d n vo hot ng chnh thc;
l cn c c quan nh nc c thm quyn kim tra, thanh tra vic chp
hnh php lut v bo v mi trng trong qu trnh hot ng ca c s./.

Ni nhn: (3)
- (4); (K, ghi h tn, chc danh, ng du)
-
- Lu:

PH LC
(Km theo Giy xc nhn s: ngy .. thng .. nm .. ca (1))
1. Cng trnh x l nc thi:
Lit k cc cng trnh x l nc thi hon thnh phc v giai on vn
hnh ca D n (hoc ca hng mc/phn k u t ca D n); m t r quy m
cng sut v quy trnh vn hnh ca cc cng trnh x l nc thi.
2. Cng trnh x l bi, kh thi:
Lit k cc cng trnh x l bi, kh thi hon thnh phc v giai on vn
hnh ca D n (hoc ca hng mc/phn k u t ca D n); m t r quy m
cng sut v quy trnh vn hnh ca cc cng trnh x l bi, kh thi.
3. Cng trnh x l, qun l cht thi rn, cht thi nguy hi:
Lit k cc cng trnh x l, qun l cht thi rn, cht thi nguy hi hon
thnh phc v giai on vn hnh ca D n (hoc ca hng mc/phn k u t
ca D n); m t r quy m cng sut v quy trnh vn hnh ca cc cng trnh
ny.
4. Cng trnh x l nhim ting n v rung:
Lit k cc cng trnh x l nhim ting n, rung hon thnh phc v
giai on vn hnh ca D n (hoc ca hng mc/phn k u t ca D n); m
t r quy m v quy trnh x l ca cc cng trnh ny.
5. Cng trnh bo v mi trng khc:
6. H s km theo Giy xc nhn:
 H s sau y c (1) ng du xc nhn trang ba v du gip lai l b phn
khng tch ri km theo Giy xc nhn ny:
B h s ngh xc nhn hon thnh cng trnh bo v mi trng vi dng
ch sau trn ba: Km theo Giy xc nhn s do (1) cp ln....ngy thng
.. nm ..".
7. Yu cu khc:
Trong qu trnh hot ng, nu c s c bt thng xy ra i vi cng trnh
bo v mi trng hoc c s thay i ni dung trong Giy xc nhn ny, Ch c s
phi bo co bng vn bn n c quan xc nhn kp thi x l hoc iu chnh
cho ph hp vi thc tin./.
Ghi ch: (1) C quan kim tra, xc nhn hon thnh cng trnh bo v mi
trng; (2) Tn y , chnh xc ca D n hoc ca hng mc/phn k u t ca
D n (2); (3) Th trng C quan kim tra, xc nhn hon thnh cng trnh bo
v mi trng; (4) Ch d n