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ESTADO DE GOIS

SECRETARIA DE MEIO AMBIENTE, RECURSOS HDRICOS, INFRAESTRUTURA, CIDADES E


ASSUNTOS METROPOLITANOS

11 Avenida n 1272 Setor Leste Universitrio Goinia-GO, CEP: 74.605-060 PABX: (62) 3265-1300 Fax: (62) 3202-3358
www.secima.go.gov.br

REQUERIMENTO
1) Solicitao para obteno de:
ESTADO DE GOIS
SECRETARIA DE MEIO AMBIENTE, RECURSOS HDRICOS, INFRAESTRUTURA, CIDADES E
ASSUNTOS METROPOLITANOS

11 Avenida n 1272 Setor Leste Universitrio Goinia-GO, CEP: 74.605-060 PABX: (62) 3265-1300 Fax: (62) 3202-3358
www.secima.go.gov.br

REQUERIMENTO
Licena Prvia LP Licena de Explorao Florestal LEF:

Licena de Instalao LI ( ) Desmatamento

( ) Inicial ( ) Ampliao ( ) Renovao ( ) Corte Floresta Nativa Plantada


Licena de Funcionamento LF ( ) Limpeza de Pastagem

( ) Inicial ( ) Ampliao ( ) Renovao ( ) Corte de rvores Isoladas


Licena de Instalao e Operao LIO ( ) Levantamento Circunstanciado

Licena Ambiental Simplificada LAS ( ) Plano de Manejo Florestal

Licena para Aquicultura LA ( ) Reflorestamento Nativo

Registro / Licenciamento RL Averbao de Reserva Legal

Parecer Tcnico PT ( ) Relocao

Autorizao / Declarao ( ) Extra-propriedade

Autorizao de Transporte e Certificado Dispensa do Licenciamento


de Destinao de Resduos Especiais
ATRE / CDRE
Outros: __________________________________________________________________________

2) Atividade:
CNAE: ______________ Atividade Principal: _________________________________________________
Atividade a ser Licenciada: _______________________________________________________________
_____________________________________________________________________________________

3) Nmero do Processo Anterior: ____________________________ Renovao: ( ) sim ( ) no


Validade ltima Licena: ____/_____/________ ( )LP ( )LI ( )LF ( )LIO ( )LAS ( )LEF ( )LA ( )RL ( ) CDRE

4) Dados do Cliente:
Nome/Razo Social:_____________________________________________________________________
Nome
Fantasia:_________________________________________________________________________
CPF/CNPJ: ________________________________ IE/CI: ____________________________________
Endereo Residencial/Localizao: _________________________________________________________
CEP: _________ - ______ Municpio: ___________________________________________ UF: ________
Coord. Geog.: Latitude: _____________________________ Longitude:____________________________
Coord. UTM: X: ___________________________________ Y: _________________________________
Tel.:( ) _______________Fax:( )_______________ Cel:( )______________ Cx. Postal:___________
Site:_________________________________________________________________________________
E-mail:_______________________________________________________________________________
Incio das Atividades: ______/______/_________ Porte: ( ) Micro ( ) Pequeno ( ) Mdio ( ) Grande

5) Contato:
Endereo Correspondncia: _______________________________________________________________
CEP: _________ - ______ Municpio: ___________________________________________ UF: ________
Tel.:( ) _______________Fax:( )_______________ Cel:( )______________ Cx. Postal:___________
Site: _________________________________________________________________________________
E-mail: _______________________________________________________________________________
Nome: _______________________________________________________________________________

6) Empreendimento / Obra (Caso no seja no endereo residencial ou de


localizao da sede) Local de exerccio Atividade:
Nome/Descrio/Razo Social:_____________________________________________________________
Nome
Fantasia:_________________________________________________________________________
CPF/CNPJ: _________________________________ IE/CI: ____________________________________
Endereo: ____________________________________________________________________________
CEP: _________ - ______ Municpio: ___________________________________________ UF: ________
ESTADO DE GOIS
SECRETARIA DE MEIO AMBIENTE, RECURSOS HDRICOS, INFRAESTRUTURA, CIDADES E
ASSUNTOS METROPOLITANOS

11 Avenida n 1272 Setor Leste Universitrio Goinia-GO, CEP: 74.605-060 PABX: (62) 3265-1300 Fax: (62) 3202-3358
www.secima.go.gov.br

REQUERIMENTO
Coord. Geog.: Latitute: _____________________________ Longitude:____________________________
Coord. UTM: X: ___________________________________ Y: _________________________________
Tel.:( ) ________________Fax:( )________________ Cel:( )_____________ Cx. Postal:__________
Outros Municpios/UF:___________________________________________________________________

7) Imvel / Propriedade Rural:


N Registro:________ Livro:________ Folhas:_______ Matrcula:_________ Data:_____/_____/_______
Comarca: _______________________________ UF:_______ N INCRA:__________________________
Nome da Propriedade:___________________________________________________________________
Localizao:___________________________________________________________________________
CEP: _________ - ______ Municpio: ___________________________________________ UF: ________
Coord. Geog.: Latitute: _____________________________ Longitude:____________________________
Coord. UTM: X: ___________________________________ Y: _________________________________
rea Total (ha/m): ____________________ Observaes: _____________________________________
_____________________________________________________________________________________
rea Reserva Legal(ha): ________________ Observaes: _____________________________________
_____________________________________________________________________________________
Extra-Propriedade: ( ) No ( ) Sim: Dados da Propriedade: ________________________
_____________________________________________________________________________________
_____________________________________________________________________________________

8) Objeto e Parmetros do Licenciamento:


rea Total do Terreno (m):______________________ rea Construda (m):______________________
rea Atividade ao Ar Livre (m):___________________ rea do Controle de Poluio (m):____________
N de Veculos Automotores (und): ________________ N de Caixas Registradoras (und): ___________
rea Inundada (ha)_____________________________ rea Irrigada (ha):_________________________
rea Lmina/Espelho dgua (m):_________________ N de Tanques:___________________________
rea Total dos Lotes (m):_______________________ Distncia de Goinia (Km):___________________
rea Explorada (ha):____________________________ rea Averbada (ha):_______________________
Extenso da Obra (Km):_______________ Potncia (Mw):_______________ Tenso (Kv):____________
N de Cabeas:___________ ( ) Bovdeos ( ) Sudeos ( ) Equdeos ( ) Aves ( ) Outros:____________

Bacia Hidrogrfica: ( ) Araguaia ( ) Paranaba ( ) Tocantins ( ) So Francisco


Corpo Receptor: _______________________________________________________________________

9) Responsvel Tcnico:
Nome:_____________________________________________Profisso:___________________________
CPF/CNPJ:______________________CI/IE:__________________Registro Profissional:_______________
Endereo: ____________________________________________________________________________
CEP: _________ - ______ Municpio: ___________________________________________ UF: ________
Tel.:( ) ______________Fax:( )_______________ Cel:( )______________ Cx. Postal:____________
Site: _________________________________________________________________________________
E-mail: _______________________________________________________________________________

10) Procurador:
Nome:_____________________________________________Profisso:___________________________
CPF/CNPJ:______________________CI/IE:__________________Registro Profissional:_______________
Endereo Correspondncia: _______________________________________________________________
CEP: _________________ - ________ Municpio: ___________________________________ UF: ______
Tel.:( ) ______________Fax:( )_______________ Cel:( )______________ Cx. Postal:____________
Site: _________________________________________________________________________________
E-mail: _______________________________________________________________________________
Nmero de Documentos Anexos: ___________________________________________________________
______________________________________________________________________________________

Declaro para os devidos fins, que o desenvolvimento das atividades relacionadas neste requerimento
realizar-se-o de acordo com os dados transcritos e anexos supramencionados, pelo que venho requerer
Secretaria do Meio Ambiente e Recursos e Hdricos do Estado de Gois.

__________________________, ______ de ______________________ de __________.


(Local e Data)

Assinatura: ____________________________________________________________________________
Nome: ________________________________________________________________________________
Cargo:_________________________________________________________________________________