KARNATAKA STATE POLLUTION CONTROL BOARD

FORM-I
(To be submitted in Duplicate)

Application for consent for discharge of emission/continuation of discharge of emission

under Section.21 of the Air (Prevention & Control of Pollution) Act, 1981
(See Rule.20)

From:

To:
The Member Secretary
Karnataka State Pollution Control Board
No. 49, Parisara Bhavan
Church street
Bangalore

Through: Environmental Officer, ________________________

I/We here by apply for the Consent for operation of the industry for the period
_______________ to __________________ under Section 21 of Air (Prevention & Control of
Pollution) Act 1974 to make emissions from the industrial plant owned by
________________________________________________________. The relevant
information is given below.

1. Name & address of the

Applicant ( Occupier’s name,
designation and correspondence
address
STD code Phone No.
Fax No.
E-mail address

2. (a) Name & address of the Industry

(Location of the Industry)

Survey No/Plot No.

STD code Phone No.

Fax No.

E-mail address

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2(b) Whether the plant area is
declared as Prohibited area: if
yes state the name of the
authority and furnish the copy of
the order which the area has
been declared as prohibited area.
2.1 Indicate the present use of the
land in the vicinity of (10 km
radius) the site.
Human settlement more than
1000 population( specify the
name of village/population and
distance from the plant)
Sanctuary- National Park-Hills-
Mountains- Mangroves,
backwaters of Reservoir etc.,
( mention the distance from the
site)
Ancient monuments( mention
the distance and direction from
the plant)
2.2(a) Total land area
Buildup area
Vacant land
Greenbelt area
2.3 Name and designation of the
person incharge of pollution
Control in the industry.
3 Size of the industry
4 Date of commissioning
5 No. of employees( The total nos.
including office staff and
contract labour and labour on
roll shall be furnished)
6 Products manufactured (Total
list of products/Byproducts with
the production capacity (licenced
and installed)/month shall be
furnished).
(a) Installed capacity
(b) Consented capacity
(c)Any diversification /
expansion ( give details)

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7 List of raw materials used per
month( tones/month)
Present raw materials used
Proposed raw material used
8 Brief manufacturing
process( please attach flowchart,
water and material balance
statement)
(a) Flow chart
(b) Water and material balance
statement & chart

9. (a) The air pollution sources are shown below:

Stack Source Type Sulphur Consumption Chimney height & air Chimney height and air
no of air of fuel content Kgs/hr T/hr in pollution control pollution control system
pollution in case case of system required as per previous
of liquid agro provided/proposed consnsent
fuel based
fuel

9(b) Detailed technical specification of air pollution control

equipment, final flue gas emission rate, temperature,
concentration of air pollutants shall be furnished in
case of new plant along with schematic flowchart
showing the source of air pollution and the pollution
control equipments in section shall be furnished.

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9(c) Details of solid/liquid waste generated during the
process of air pollution control/
Solid
(1) Bottom ash
(2)Fly ash
(3) other solid waste/by product
Type of handling and disposal
(1) write up
(2) Schematic diagram
(3) Future use
Liquid
(1) Quantity
(2) Characteristics
(3) Mode of storage and handling.

10. Analysis report of each air pollution source ( mg/Nm3)

Stack Gas Temp Exit gas Analysis of flue gas process/emission
attached quantity velocity
to
SO2 SPM CO2 CO NOx HC Other

11. Ambient air quality data:

11(a) For new industry, background emission data and
GLC’s after installation of proposed industry shall
be furnished
11(b) The existing industry shall furnish the statistical
interpretation of AAQ data collected during the
previous consent period along with graphical
representation
12 Whether the air pollution control systems are
completely put up and are in operation.
13 Whether the air pollution control systems are
letting the emissions within the standards
stipulated by the Board
14 Date, Month and year by which the air pollution
control system will be completely put up
15 Noise pollution
Source

Noise control measures

Noise level at plant boundary

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16 Whether the environmental management system
followed by the industry/local
authority/layout/township( attach details)
17 Whether covered under the PLI Act, if so
furnished a policy No, Expiry date and the
insurance amount.
18(a) Total grass capital investment of the unit in
Rupees (this shall be inclusive of land, building,
Plant and machinery and other movable and
immovable assets in the name of the industry
without depreciation. Please enclose copy of the
extract from the Balance Sheet with latest fixed
investment schedule.
18(b) The estimated expenditure/ incurred for
implementation of air pollution control measures
18© Estimate cost for upgradation of air pollution
control measures, give all the details and the
proposed date of completion of this work
18(d) Annual operation and maintenance cost of air
pollution control measures

19. Consent fee details.

DD.No.________________ Dated _________________ for Rs._______________ in
favour of ‘Karnataka State Pollution Control Board’ ,as fees payable under Section 21
of the Act & Rule 20 of the Air Rules.

20. I/We further declare that the above furnished information is true & correct to the best of
my/our knowledge. I am aware that the any wrong information furnished, is punishable
under Air Act.

21. I/We hereby submit that, in case of charge either of the point of discharge or the quantity of
discharge or its quality fresh application for consent shall be made & until such consent is
granted no change shall be made.

22. I/We hereby agree to submit to the State Board any application for renewal of consent four
months in advance date of expiry of the consent for outlet/discharge if to be continued
thereafter.

23. I/We undertake to furnish any other information within one month of its being called by the
State Board.

Yours faithfully

(Name and signature of the Occupier)

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INSTRUCTIONS FOR FILLING UP & SUBMITTED THE APPLICATION

1. Do not leave any columns blank. Write N.A. for whichever is not applicable.
Incomplete application will not be processed and will be considered as incomplete

2. Submit the application for renewal atleast 120 days in advance prior to the expiry date.

3. Submit the application in duplicate along with the following documents to the
Divisional Office/Regional Office concerned of the Board while retaining one copy
with you for your reference. Applications pertaining to Bangalore Regional Offices
shall be submitted at Helpdesk, Karnataka State Pollution Control Board, No.49,
Parisara Bhavana, Church Street, Bangalore-01.

(a) SSI Certificate if applicable

(b) Latest audited balance sheet (fixed assets schedule).
(c) Manufacturing process flow-chart
(d) Compliance to the previous consent conditions if any.
(e) Latest analysis report of the effluents/stack emission report.
(f) Panchayat license or any other licenses obtained incase of consent for establishment.
(g) Land conversion certificate in case of consent for establishment.
(h) Required consent fee in the form of D.D. in favour of Karnataka State Pollution Control
Board as per Annexure I enclosed on the fixed assets of the industry including land,
building plant & machinery & any other movable or immovable assets in the name of
the factory as per the gross block value of the fixed assets schedule of the balance sheet.

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 Annexure-I

CONSENT FEE STRUCTURE

(with effect from 2-4-1998 under Air Act and 20-04-1998 under Water Act)
Sl Capital investment by industries Consent fee in rupees for different
no categories of industries
RED ORANGE GREEN
(a) Exceeding Rupees 1000 crores 2,00,000 1,75,000 1,50,000

(b) Exceeding Rupees 500 crores but not 1,50,000 1,25,000 1,00,000
exceeding Rupees 1000 crores

(c) Exceeding Rupees 250 crores but not 1,00,000 90,000 75,000
exceeding Rupees 500 crores

(d) Exceeding Rupees 50 crores but not 75,000 60,000 50,000

exceeding Rupees 250 crores

(e) Exceeding Rupees 25 crores but not 50,000 40,000 30,000

exceeding Rupees 50 crores

(f) Exceeding Rupees 10 crores but not 30,000 25,000 20,000

exceeding Rupees 25 crores

(g) Exceeding Rupees 5 crores but not 20,000 17,500 15,000

exceeding Rupees 10 crores

(h) Exceeding Rupees 1 crore but not 15,000 12,500 10,000

exceeding Rupees 5 crores

(i) Exceeding Rupees 50 lakhs but not 6,000 5,000 4,000

exceeding Rupees 1 crore

(j) Exceeding Rupees 25 lakhs but not 3,000 2,500 2,000

exceeding Rupees 50 lakhs

(k) Exceeding Rupees 10 lakhs but not 2,000 1,750 1,500

exceeding Rupees 25 lakhs

(l) Exceeding Rupees 5 lakhs but not 1,500 1,250 1,000

exceeding Rupees 10 lakhs

(m) Exceeding Rupees 1 lakhs but not 500 250 200

exceeding Rupees 5 lakhs

(n) Rupees 1 lakh and below 200 150 100

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