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Senin, 18 April 2011

CONTOH FORMULIR ISIAN IZIN PEMBUANGAN LIMBAH CAIR KE LAUT


FORMULIR ISIAN IZIN PEMBUANGAN
LIMBAH CAIR KE LAUT


I.      INFORMASI UMUM

A.   Pemohon

1. Nama Pemohon                                : .............................................................................

2. Jabatan                                               : .............................................................................

3. Alamat                                                 : .............................................................................

4. Nomor Telepon/Fax.                         : .............................................................................

5. Nama Perusahaan                            : .............................................................................

6. Nama Penanggung Jawab Usaha
    dan/atau Kegiatan                             : .............................................................................

7. Alamat                                                 : .............................................................................

8. Nomor Telepon/Fax.                         : .............................................................................

9. Bidang Usaha                                    : .............................................................................

10. Akte Pendirian                                 : .............................................................................

11. Nomor Persetujuan Prinsip           : .............................................................................

12. NPWP                                               : .............................................................................

13. Jenis Produksi                                 : .............................................................................

14. Kapasitas Produksi                         : .............................................................................



B.   Izin dan Dokumen Lingkungan yang telah diperoleh:

No.
Nama Izin dan Dokumen
Instansi
Pemberi Izin
Nomor
Tanggal Berlaku

1.
2.
Dokumen AMDAL/UKL/UPL
Izin yang berkaitan dengan
pengelolaan limbah lainnya






C.   Sumber Air Baku

No.
Nama Sumber
Kapasitas Pengambilan
Keterangan











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