FORM-3

APPLICATION FOR AMENDMENT IN TOR

Detrils of Pro

Joint Venture (YesNo

Address ofthe Email ld of Mobile No. of

JV Partner JV Partner JV Partngr

Addre$s for the

Name ofthe applicant
Designation (Owner / Partncr / CEO
Address
Pin coa"

"--ait
TeleDhone No.
Fax No.
Category ofthe Proiect/Activity as per Schedule ofEIA Notification, 2006
Project / Activity
[l(axi) / r(axii) / t(b) / t(c\ / 1(d) / 1 (c) / 2(^) / 2(b) / 3(a) / 3(b, / 4(a) /
a(bxi)/ aG) (ii) / 4(c) / 4(d) t 4(.\ / a(D t 5(&) / s(b) / 5(c) / 5(d) / 5(e) / 5(0 /
5(g) / 5(h) / 5(i) / 5(j) / 6(a)/ 6(b\/ 7 (a) t 7 (b\/ 7 (c) / 7 (d) t 7 (da) / 7 (e) / 7 (t)
/ 7 Ipt / 7 th) / 7 tit I 8 h\ / I
lf Br or B:
R.q!9!_.!]I3pp!.Eq!!q! qllenlral Levet/ State level (in case of82 proiccrs

Locstion of the Proiect

Plot / S / Khasra No.
vi
Tehsil

Bounded Latitudes (North

From
To
Boundcd Longitudes ( East

of lndia T SheetNo.

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 Details ofTerms of Reference
Date ofissuc ofToR
b MoBF&CC / SEIAA File No.
c UDIoad ToR letter (PDF Onlv)
Details ofProduct
Mode ofTransport /
per II
Product / Activity Quantity Quantity Unit
(Capac ity/Area) As proposed Transmission of Product
approved
ToR

- Unit:- (rons per Annun(TPA), Mega l{att(M{), Hectares(ha), KlIo Lit.e pe. oay(KLO),
Tons crush€.l per 0ay(TCD), cublc r4etef per Dry, Xllon€ters(Km), illion Liters per
Day( LD),0thers)
- llode ofTransport/Transmission olProducl (Road, Ratl, Conveyor Belt, pipe Conveyor,
A.taI Rop€lay, conbination of tt{o or three nod€s, others)
1 Details ol'Configuration (Muhit le Entrtes lllo]9edl
Plant / Flquiprnent / Existing Proposcd Final configuration Remarks il'
Facility Confisuration Confisuration after amendment any

8 Reasonsfor tbe amendment ln ToRs

9 Any Other Anendment required
Reference of Description as per Description as Remarks
I
approved ToR approved ToR per proposal

l0 Details of EIA Consultant

Have 1ou hired ( onsultant for prcparing document (Yes/l.,1or?
IfNo,
(i) Reason for not engaging the Consultant
lfYes,
(i) Accreditation No.
(ii) Name ofthe EIA Consultant
(iii) Address
(iv) Mobile No.
(v Landline No.
(v E-mail Id
(vii) Category of Accreditation (Eligiblc fbr Caregory A/ Eligible for
Category B)
(viii) Sector of Accreditation
(ix) Validity of Accredilarion
(x) Upload Ca(ificate ofAccreditation certified,by QCINABET (Uploud pdf
Onlv)
ll Documentu to be altached

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 a, Upload Copy ofrevised Fonn-|
b. Upload revised pre-feasibility report
c. Upload Cover Letter duly si$ed by th€ proj€ct proponent o. authorized
oerson (UDload Ddfonlv)
Upload a oopy of authorization duly signed by the project pmponent in
support of the person making this application on behalf of the User
Ase ncv ftlp load Ddf only)
Upload Additional File,ifany (Upload pdJ only)
ll Utrdertaki||g
I hereby give undeftaking that the data and ioformation given in the application and
enclosures are true to be best ofmy knowledge and beliefand I am aware that ifany part of
the data atld information found to b€ false or misleading at any stage, the project will be
rcjected and clearance given, if any to the project will be revoked at our .isk and cost. In
addition to above, I hereby give undertaking that no activity / construotion / expansion has
since b€en taken uD
b. Name
c. Designation
d. Company
Addrcss

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