MODEL DocuUNE NT - Affidavit fr Dist Cwiterna t Before the Notary To accompany the application for Consent-to-Establish (Noc) submitted by the proponent under the provisions of the water (Prevention and Control of Pollution)Act, 1974 and the Air (Prevention and Control of Pollution) Act, 1981. AFFIDAVIT By this indenture | $/0,0/0. Village. P.O, PS, District Pin Code Solemnly declare and state as hereunder: We are going to establish a mill/factory with capacity in the name of M/S. a Plot No. of khata No. Mauza Po. PS. District, 2. That the distance of my plant from following landmarks are as here under:- (a) From NH/SH_ Kee (b) From forest km/m, (c) From Railway line. km/m (4) From Habitation, km/m (ERI eae Ra {f) From Hospital, Km/m. (e)FromCourt__ Kf (h) From River, km/m ‘That the above statement are true to the the best of my knowledge and belief and in the event of the above details proving wrong, the Consent-to Establish (NOC) and Consent-to-Operate granted to me subsequently on the basis of this affidavit, shall stand revoked and | shall also be liable to be proceeded against legally And in the event of violation and subsequent revocation of my CTE/CTO, any financial damage or loss in such case shall be my responsibility Date: Dedpondent Place : Identity