PH LC 5.

5
CU TRC V NI DUNG CA K HOCH BO V MI TRNG
THUC THM QUYN XC NHN NG K
CA S TI NGUYN V MI TRNG
(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)
CNG HA X HI CH NGHA VIT NAM
c lp - T do - Hnh phc
---------------
(a danh ni thc hin d n), ngy... thng... nm...
Knh gi: (1)
Chng ti gi n (1) bn k hoch bo v mi trng ng k vi cc ni
dung sau y:
I. Thng tin chung
1.1. Tn d n, phng n sn xut, kinh doanh, dch v (gi chung l d
n): nu ng tn gi nh c nu trong bo co u t (bo co nghin cu kh
thi hoc ti liu tng ng).
1.2. Tn ch d n: ...
1.3. a ch lin h: ...
1.4. Ngi i din theo php lut: ...
1.5. Phng tin lin lc vi ch d n: (s in thoi, s Fax, E-mail ...).
1.6. a im thc hin d n:
M t v tr a l (ta cc im khng ch ranh gii theo h VN2000) ca
a im thc hin d n km theo s minh ha ch r cc i tng t nhin
(sng ngi, ao h, ng giao thng,), cc i tng v kinh t - x hi (khu dn
c, khu th; c s sn xut, kinh doanh, dch v; cng trnh vn ha, tn gio, di
tch lch s,... ), hin trng s dng t trn v tr thc hin d n v cc i tng
xung quanh khc.
Ch r ngun tip nhn nc thi ca d n km theo cc tiu chun, quy chun
k thut v mi trng hin hnh p dng i vi cc ngun ny.
1.7. Quy m d n
M t tm lc v qu trnh thi cng xy dng; quy m/cng sut sn xut;
cng ngh sn xut; lit k danh mc cc thit b, my mc km theo tnh trng ca
chng.
1.8. Nhu cu nguyn liu, nhin liu s dng
- Nhu cu v nguyn liu, nhin liu phc v cho sn xut c tnh theo gi,
ngy, thng hoc nm; phng thc cung cp nguyn liu, nhin liu.
- Nhu cu v ngun cung cp in, nc cho sn xut.
Yu cu:
- i vi trng hp m rng, nng cp, nng cng sut ca c s sn xut,
kinh doanh, dch v ang hot ng cn phi b sung thng tin v c s ang hot
ng, c bit l cc thng tin lin quan n cc cng trnh, thit b, hng mc, cng
ngh s c tip tc s dng hoc loi b hoc thay i, iu chnh, b sung.
II. Cc tc ng xu n mi trng
2.1. Tc ng xu n mi trng do cht thi
2.1.1. Kh thi: ...
2.1.2. Nc thi: ...
2.1.3. Cht thi rn: ...
2.1.4. Cht thi nguy hi: ...
2.1.5. Cht thi khc:... (nu c)
i vi mi loi cht thi phi nu cc thng tin v: ngun pht sinh, tng
lng pht sinh trn mt n v thi gian, thnh phn cht thi. i vi kh thi v
nc thi cn phi nu r hm lng/nng ca tng thnh phn nhim c trng
v so snh vi tiu chun, quy chun, quy nh hin hnh trong trng hp cha p
dng cc bin php gim thiu tc ng xu.
2.2. Tc ng xu n mi trng khng do cht thi
Nu tm tt cc tc ng xu n mi trng khc (nu c) do d n gy ra:
xi mn, trt, st, l, ln t; s xi l b sng, b sui, b h, b bin; s bi
lng lng sng, lng sui, lng h; s thay i mc nc mt, nc di t; xm
nhp mn; xm nhp phn; s bin i vi kh hu; s suy thoi cc thnh phn mi
trng; s bin i a dng sinh hc v cc yu t khc.
Yu cu: cc loi tc ng xu n mi trng phi c th hin theo tng
giai on, bao gm mt, mt s hoc ton b cc giai on sau theo c th ca
tng d n c th: (1) chun b u t, (2) thi cng xy dng, (3) vn hnh d n v
(4) hon thnh d n.
III. K hoch bo v mi trng
 3.1. Gim thiu tc ng xu do cht thi
- Mi loi cht thi pht sinh u phi c km theo bin php gii quyt tng
ng v c thuyt minh v mc kh thi, hiu sut/hiu qu gii quyt. Trong trng
hp khng th c bin php hoc c nhng kh kh thi trong khun kh ca d n
phi nu r l do v c kin ngh c th cc c quan lin quan c hng gii
quyt, quyt nh.
- Phi chng minh sau khi p dng bin php gii quyt th cc cht thi s
c x l n mc no, c so snh, i chiu vi cc tiu chun, quy chun, quy
nh hin hnh. Trng hp khng p ng c yu cu quy nh th phi nu r
l do v c cc kin ngh c th cc c quan lin quan c hng gii quyt, quyt
nh.
3.2. Gim thiu cc tc ng xu khc
Mi loi tc ng xu pht sinh u phi c km theo bin php gim thiu
tng ng, thuyt minh v mc kh thi, hiu sut/hiu qu gim thiu tc ng
xu . Trng hp khng th c bin php hoc c nhng kh kh thi trong khun
kh ca d n th phi nu r l do v c kin ngh c th cc c quan lin quan
c hng gii quyt, quyt nh.
3.3. K hoch gim st mi trng
- Gim st lu lng kh thi, nc thi v nhng thng s nhim c trong
kh thi, nc thi c trng cho d n, ph hp vi quy chun k thut v mi
trng hin hnh, vi tn sut ti thiu mt (01) ln/06 thng. Khng yu cu ch
d n gim st nc thi i vi d n c u ni nc thi x l ti h thng x
l nc thi tp trung v khng yu cu ch d n gim st nhng thng s nhim
c trong kh thi, nc thi m d n khng c kh nng pht sinh hoc kh nng
pht sinh thp.
- Cc im gim st phi c th hin c th trn s vi ch gii r rng
v ta theo quy chun hin hnh.
Yu cu:
- Ngoi vic m t bin php gim thiu tc ng xu n mi trng nh
hng dn ti mc 3.1 v 3.2 Ph lc ny, bin php gim thiu tc ng xu n
mi trng mang tnh cng trnh phi c lit k di dng bng, trong nu r
chng loi, c tnh k thut, o lng cn thit v km theo tin xy lp c th
cho tng cng trnh.
- i vi i tng m rng quy m, nng cp, nng cng sut, ni dung ca
phn III Ph lc ny cn phi nu r hin trng cc cng trnh, bin php bo v
mi trng hin c ca c s hin hu v mi lin h ca cc cng trnh ny vi h
thng cng trnh, bin php bo v mi trng ca d n ci to, nng cp, nng
cng sut.
IV. Cam kt
Chng ti cam kt v vic thc hin cc bin php gim thiu tc ng xu n
mi trng nu trong k hoch bo v mi trng t cc quy nh, tiu chun, quy
chun k thut v mi trng v thc hin cc bin php bo v mi trng khc
theo quy nh hin hnh ca php lut Vit Nam.
Chng ti gi km theo y cc vn bn c lin quan n d n (nu c v lit
k c th).
Chng ti bo m v trung thc ca cc thng tin, s liu, ti liu trong bn
k hoch bo v mi trng, k c cc ti liu nh km. Nu c sai phm, chng ti
xin hon ton chu trch nhim trc php lut ca Vit Nam.
(2)
(K, ghi h tn, chc danh, ng du (nu c))
Ghi ch: (1) C quan xc nhn ng k k hoch bo v mi trng; (2) i din
c thm quyn ca ch d n.
Yu cu: Bn k hoch bo v mi trng c lp thnh ba (03) bn gc, c ch
k ca ch d n pha di tng trang v k, ghi h tn, chc danh, ng du (nu
c) ca i din c thm quyn ca ch d n trang cui cng.