Form I
(See rule 8)
Application for Authorisation
(To be submitted in duplicate)
To
The Prescribed Authority
(Name of the State Govt./UT Administration)
Address.
1. Particulars of Applicant
(i) Name of the Applicant (In block letters and in full)
(ii) Name of the Institution
Address:
Tele. No., Fax No. Telex No.
2. Activity for which authorisation is sought
(i) Generation
(ii) Collection
(iii) Reception
(iv) Storage
(v) Transportation
(vi) Treatment
(vii) Disposal
(viii) Any other form of handling
3. Please state whether applying for resh authorisation or for renewal (In case of renewal previous authorisation-number and date)
4. (i) Address of the institution handling biomedical 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 biomedical waste
(ii) Mode(s) of treatment
6. Brief description of method of treatment and disposal (attach details):
7. (i) Category (see Schedule I) of waste to be handled
(ii) Quantity of waste (category-wise) to be handled per month
8. Declaration
I do hereby declare that the statement 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
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