ESTADO DE GOIS

SECRETARIA DO MEIO AMBIENTE E DOS RECURSOS HDRICOS

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

REQUERIMENTO
1) Solicitao para obteno de:

Licena Prvia LP

Licena de Instalao LI

( ) Desmatamento

( ) Inicial ( ) Ampliao ( ) Renovao

( ) Corte Floresta Nativa Plantada

( ) Limpeza de Pastagem

Licena de Funcionamento LF
( ) Inicial ( ) Ampliao ( ) Renovao

Licena de Explorao Florestal LEF:

Licena de Instalao e Operao LIO

( ) Corte de rvores Isoladas

( ) 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: _________________________________________________

Registro de Produo de Carvo Vegetal

Atividade a ser Licenciada: _______________________________________________________________

_____________________________________________________________________________________
( ) sim X( ) no
( )LP ( )LI ( )LF ( )LIO ( )LAS ( )LEF ( )LA ( )RL ( ) CDRE

3) Nmero do Processo Anterior: ____________________________ Renovao:

Validade ltima Licena: ____/_____/________

4) Dados do Cliente:

Pedro Rodrigues de Souza

Nome/Razo Social:_____________________________________________________________________
Nome
301.857.856-20
Fantasia:_________________________________________________________________________
CPF/CNPJ: ________________________________
IE/CI: ____________________________________
Av. Desor. Hamilton Velasco Qd 56-a Lt 12 St - Centro
Endereo Residencial/Localizao: _________________________________________________________
Britnia
76 280
000
CEP: _________
- ______
Municpio: ___________________________________________ UF: ________
Coord. Geog.: Latitude: _____________________________ Longitude:____________________________
Coord. UTM: X: ___________________________________ Y: _________________________________
62 )______________
9956-1527
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:_________________________________________________________________________

ESTADO DE GOIS
SECRETARIA DO MEIO AMBIENTE E DOS RECURSOS HDRICOS
11 Avenida n 1272 Setor Leste Universitrio Goinia-GO, CEP: 74.605-060 PABX: (62) 3265-1300 Fax: (62) 3202-3358
www.semarh.goias.gov.br

REQUERIMENTO
CPF/CNPJ: _________________________________ IE/CI: ____________________________________
Endereo: ____________________________________________________________________________
CEP: _________ - ______ Municpio: ___________________________________________ UF: ________
Coord. Geog.: Latitute: _____________________________ Longitude:____________________________
Coord. UTM: X: ___________________________________ Y: _________________________________
Tel.:( ) ________________Fax:( )________________ Cel:( )_____________ Cx. Postal:__________
Outros Municpios/UF:___________________________________________________________________

7) Imvel / Propriedade
Rural:
X

01
1985
25
16
1.882
2-G
N Registro:________ Livro:________
Folhas:_______ Matrcula:_________ Data:_____/_____/_______
GO
Comarca: Aragaras
_______________________________ UF:_______
N INCRA:__________________________
Fazenda
Galheiro
de
Baixo
Nome da Propriedade:___________________________________________________________________
Localizao:___________________________________________________________________________
Mun. De Bom Jardim de Gois
GO
CEP: _________ - ______ Municpio: ___________________________________________ UF: ________
-16.07822
-52.06456
Coord. Geog.: Latitute: _____________________________ Longitude:____________________________
Coord. UTM: X:386213.669
___________________________________ Y:8222149.906
_________________________________
367,23.50
ha
rea Total (ha/m): ____________________ Observaes: _____________________________________
_____________________________________________________________________________________
ha
rea Reserva Legal(ha): 73,47.70
________________
Observaes: _____________________________________
_____________________________________________________________________________________
Extra-Propriedade: (X ) 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:

Eng. Agronomo

Jos Eustaquio Alves

Nome:_____________________________________________Profisso:___________________________
Crea 567/D-GO
039.950.201-78
CPF/CNPJ:______________________CI/IE:__________________Registro
Profissional:_______________
5
AV.
Qd.102,
Lt.15,
N174,
C
St.
Leste
Universitrio
Endereo: ____________________________________________________________________________
74 605
040
Goiania
CEP: _________ - ______ Municpio: ___________________________________________ UF:GO
________
62
3202-9080
Tel.:( ) ______________Fax:( )_______________ Cel:( )______________ Cx. Postal:____________
Site: _________________________________________________________________________________
E-mail: _______________________________________________________________________________

10) Procurador:

Paulo Vitor da Cruz Belga

Assessor Ambiental
Nome:_____________________________________________Profisso:___________________________
021.115.301-07
CPF/CNPJ:______________________CI/IE:__________________Registro
Profissional:_______________
Rua 226, Qd 101, Lt 16 St. Leste Universitrio
Endereo Correspondncia: _______________________________________________________________
74 610
130
GO
CEP: _________
- ______
Municpio: Goinia
___________________________________ UF: ______
62
3205-2862
62
8147-0962
Tel.:( ) ______________Fax:( )_______________ Cel:( )______________ Cx. Postal:____________
Site: _________________________________________________________________________________
E-mail: _______________________________________________________________________________

Nmero de Documentos Anexos: ___________________________________________________________

______________________________________________________________________________________

ESTADO DE GOIS
SECRETARIA DO MEIO AMBIENTE E DOS RECURSOS HDRICOS
11 Avenida n 1272 Setor Leste Universitrio Goinia-GO, CEP: 74.605-060 PABX: (62) 3265-1300 Fax: (62) 3202-3358
www.semarh.goias.gov.br

REQUERIMENTO
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:_________________________________________________________________________________