1. (a) Name and Address of the project proposed :

(b)   Location of the project:

Name of the Place:

District, Tehsil:


Nearest Airport/Railway Station :

(c)   Alternate sites examined and the reasons for selecting the proposed site:

(d) Does the site conform to stipulated land use as per local land use plan:


2.            Objectives of the project:

3.            (a) Land Requirement:

Agriculture Land:

Forest land and Density of vegetation.

Other (specify):

(b) (i) Land use in the Catchment within 10 kms radius of the proposed site:

(ii)   Topography of the area indicating gradient, aspects and altitude:

(iii) Erodibility classification of the proposed land:

(c) Pollution sources existing in 10 km radius and their impact on quality of air, water and land:

(d)   Distance of the nearest National Park/Sanctuary/Biosphere Reserve/Monuments/heritage site/Reserve Forest:

(e)   Rehabilitation plan for quarries/borrow areas:

(f)     Green belt plan:

(g)   Compensatory afforestation plan:

4. Climate and Air Quality:

(a)    Windrose at site:

(b)   Max/Min/Mean annual temperature:

(c)    Frequency of inversion:

(d)   Frequency of cyclones/tornadoes/cloud burst:

(e)    Ambient air quality data:

(f)     Nature & concentration of emission of SPM, Gas (CO, CO2, NOx, CHn etc.) from the project:

5.      Water balance:

(a) Water balance at site:

(b)                                                   Lean season water availability;

Water Requirement:

(c)   Source to be tapped with competing users (River, Lake, Ground, Public supply):

(d)   Water quality:

(e)   Changes observed in quality and quantity of groundwater in the last years and present charging and extraction details:

(f)                                                     (i) Quantum of waste water to be released with treatment details:

(ii)               Quantum of quality of water in the receiving body before and after disposal of solid wastes:

(iii)             Quantum of waste water to be released on land and type of land:

(g) (i) Details of reservoir water quality with necessary Catchment Treatment Plan:

(ii) Command Area Development Plan:

6.                                                                  Solid wastes:

(a)    Nature and quantity of solid wastes generated

(b)   Solid waste disposal method:  

7.                                                                  Noise and Vibrations:

a.                  Sources of Noise and Vibrations:

b.                  Ambient noise level:

c.                  Noise and Vibration control measures proposed:

d.                  Subsidence problem, if any, with control measures:

8.                                                                  Power requirement indicating source of supply: Complete environmental details to be furnished separately, if captive power unit proposed:

9.                                                                  Peak labour force to be deployed giving details of:

    • Endemic health problems in the area due to waste water/air/soil borne diseases:
    • Health care system existing and proposed:

10. (a) Number of villages and population to be displaced:

(b)                                                                           Rehabilitation Master Plan:

11.             Risk Assessment Report and Disaster Management Plan:

12. (a) Environmental Impact Assessment

(b) Environment Management Plan:

(c)    Detailed Feasibility Report:

(d)                     Duly filled in questionnaire


 Report prepared as per guidelines issued by the Central Government in the MOEF from time to time:

1.                  Details of Environmental Management Cell:

I hereby give an undertaking that the data and information given above are due to the best of my knowledge and belief and I am aware that if any part of the data/information submitted is found to be false or misleading at any stage, the project be rejected and the clearance given, if any, to the project is likely to be revoked at our risk and cost.

Signature of the applicant

With name and full address


Given under the seal of Organisation

on behalf of Whom the applicant is signing.





In respect to item for which data are not required or is not available as per the declaration of project proponent, the project would be considered on that basis.



Note : The application shall be made in the Form A specified in Schedule-II annexed to this notification and shall be accompanied by a detailed project report which shall, interalia, include an Environmental Impact Assessment Report and an Environment Management plant prepared n accordance with the guidelines issued by the State Department of Environment from time to time.