To

The Prescribed Authority
(Name of the State Govt/UT Administration)
Address.

(i) Name of the Applicant
(In block letters & in full)
(ii) Name of the Institution:
Address:
Tele No., Fax No. Telex No.

(i) Generation
(ii) Collection
(iii) Reception
(iv) Storage
(v) Transportation
(vi) Treatment
(vii) Disposal
(viii) Any other form of handling

(i) Address of the institution handling bio-medical wastes:

(ii) Address of the place of the treatment facility:

(iii) Address of the place of disposal of the waste:

5.

(i) Mode of transportation (in any) of bio-medical waste:

(ii) Mode(s) of treatment:

6. Brief description of method of treatment and disposal (attach details):

7.

(i) Category (see Schedule 1) of waste to be handled

(ii) Quantity of waste (category-wise) to be handled per month

8. Declaration

I do hereby declare that the statements made and information given above are true to the best of my knowledge and belief and that I have not concealed any information.

I do also hereby undertake to provide any further information sought by the prescribed authority in relation to these rules and to fulfill any conditions stipulated by the prescribed authority.

Date:                                                                                    Signature of the Applicant

Place:                                                                                   Designation of the Applicant

 

Schedule 1, Schedule 2, Schedule 3, Schedule 4, Schedule 5, Schedule 6

Form 1, Form 2, Form 3