Signature of the Occupier or

Operator of the disposal facility

Date..............

Place.............

Form 5

[See rules 13 (1) and 14 (1)]

Application for Import or Export of Hazardous and other Waste for reuse or Recycling or Recovery or Co-Processing or Utilisation

To be Filled in by Applicant

S. No.

Description

Details to be furnished by the importer or

exporter

(1)

(2)

(3)

1.

Importer or Exporter (name and address) in India

Contact person

Tel, fax and e-mail

Facility location/address

Reason for import or export

2.

Importer or exporter (name and address) outside of India

3.

Details of waste to be imported or exported

(a)

Quantity

(b)

Basel No.

(c)

Single/multiple movement

(d)

Chemical composition of waste (attach details), where

applicable

(e)

Physical characteristics

(f)

Special handling requirements, if applicable

4.

For Schedule III A hazardous waste whether Prior Informed

Consent has been obtained

5.

For importer

(a)

Process details along with environmental safeguard measures

(attach separate sheet)

(b)

Capacity of recycling or co-processing or recovery or

utilization

Enclose a copy each of valid authorisation and valid

consent to operate from SPCB

6.

Details of import against the Ministry of Environment, Forest

and Climate Change permission in the previous three years

7.

Port of entry