Declaration Template: Indicator 1.

4B
Data/Declaration required for Q3:

Water Bodies
Whether 100% of the water bodies are free from
floating/visible solid waste? Yes  No 
Whether the areas near all the water bodies are free from
open dumpsites? Yes  No 
Whether sweeping & cleaning arrangements are in place &
No Garbage Vulnerable Points (GVPs) are present near the Yes  No 
water bodies?
Whether adequate twin-litterbins are placed at every 50
meters of water bodies? Yes  No 
Whether there is placement of anti-littering message every
50 mtrs of the water bodies? Yes  No 
Whether there is any discharge of sewage/septic tank
effluent into the water bodies? Yes  No 
Documents to be submitted by the ULB for evaluation: (For months of Nov, Dec & Jan)

Photographs of the water bodies and nearby areas showing

no floating /visible solid waste, non-existence of open
dumpsites, non-existence of Garbage Vulnerable points Attached  Not Available. 
(GVPs), placement of twin litter bins and anti-littering
messages at every 50 mtrs.

I hereby declare that the data/information provided above table, on Swachhatam portal and in the attached
documents is true to the best of my knowledge and reflects the status of the progress on ground in the ULB.

Signature & Stamp of the Nodal Officer/Head of the ULB

Name: ULB Code:
Designation: ULB Name:
Date:

Prepared by