Application (Form II) for Bio-Medical Waste Authorisation

Form II

(See rule 10)

APPLICATION FOR AUTHORISATION OR RENEWAL OF AUTHORISATION

(To be submitted by an occupier of health care facility or commerce bio-medical waste treatment facility)

To
The Member Secretary,

Delhi Pollution Control Committee,

5^th Floor, ISBT Building,

1. Particulars of Applicant:

• Name of Applicant: (IN BLOCK LETTERS AND IN FULL)
• Name of the health care facility (HCF) or common bio-medical waste treatment facility (CBWTF)
• Address for correspondence:
• Mobile No:
• Tele No., Fax No:
• Email:
• Website Address:

2. Activities for which authorization is sought:

Activity                                                                                                        Please tick

Generation, Segregation

Collection,

Storage

Packaging

Reception

Transportation

Treatment or Processing or Conversion

Recycling

Disposal or Destruction use

Offering for sale, transfer

Any other form of handling

3. Application for fresh or renewal of authorization (please tick whatever is applicable):
4. i) Applied for CTO/CTE Yes/No
5. ii) In case of renewal previous authorisation number and date:

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iii) Status of Consents:

(a) under the Water (Prevention and Control of Pollution) Act, 1974

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(b) under the Air (Prevention and Control of Pollution) Act, 1981:

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4. (i) Address of the health care facility (HCF) or common bio-medical waste treatment facility (CBWTF):

(ii) GPS coordinates of health care facility (HCF) or common bio-medical waste treatment facility

(CBWTF):

5. Details of health care facility (HCF) or common bio-medical waste treatment facility (CBWTF):

• Month & Year of Establishment
• Number of beds of HCF:
• Whether the HCE is located in Sewered Area: Yes No
• Status of Laundry existence: Yes No
• Number of patients treated per month by HCF:
• Number healthcare facilities covered by CBMWTF: ______
• No of beds covered by CBMWTF: ______
• Installed treatment and disposal capacity of CBMWTF:_______ Kg per day
• Quantity of biomedical waste treated or disposed by CBMWTF:_____ Kg/day
• Area or distance covered by CBMWTF:______________

(pl. attach map a map with GPS locations of CBMWTF and area of

coverage) (xi) Quantity of Biomedical waste handled, treated or disposed:

6. Brief description of arrangements for handling of biomedical waste (attach details):

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

(ii) Details of treatment equipment (please give details such as the number, type & capacity of each

unit)

No of units                                    Capacity of each unit

Incinerators: Plasma

Pyrolysis: Autoclaves:

Microwave: Hydroclave:

Shredder:

Needle tip cutter

or destroyer

Sharps encapsulation or

concrete pit:

Deep burial pits: Chemical

disinfection: Any other

treatment equipment:

7. Contingency plan of common bio-medical waste treatment facility (CBWTF)(attach documents):
8. Details of directions or notices or legal actions if any during the period of earlier authorisation
9. Declaration

I do hereby declare that the statements made and information given above is 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