dk;kZy; fpfdRlk vf/kdkjh

izHkkjh
izkFkfed LokLF; dsUnz eksMd xkao
ftyk dksVk ¼jkt-½
dzekad /ih,plh/2018/145 fnukad 21-08-2018

lsokesa]
Jheku Cykd eq[; fpfdRlk vf/kdkjh egksn;]
Cykd%&pspV ftyk dksVkA

fo"k;%& MNDY ,oa MNJY dh lwpuk fHktokus ckcr~A

egksn;]
mijksDr mijksDr fo’k;kUrxZr fuosnu gS fd vkids }kjk eq[;eU=h fu
%”kqYd nok ;kstuk fd pkgh xbZ lwpuk fuEu izdkj ls gS%&
Dz funsZ”kkuqlkj laLFkku esa fu%”kqYd miyC/k u gksus dk
la miyC/k djkbZ tkus miyC/k nok;sa tks dkj.k
okyh nokvksa dh nokvksa dh miyC/k
lwph lwph ughs gSaA
1 2 3 4 5
1 319 175 144 MhMhlh esa
miyC/krk u gksuk
eq[;eU=h fu%”kqYd tkWp ;kstuk
Dz la funsZ”kkuqlk laLFkku esa Tkap tks miyC/k u
j miyC/k miyC/k miyC/k ughs gksus dk
djkbZ tkus tkapksa dh gSaA dkj.k
okyh tkapksa lwph
dh lwph
1 2 3 4 5
1 15 8 7 Hkou vHkko

Mk0 fxfjjkt vxzoky

 fpfdRlk vf/kdkjh izHkkjh
izkFkfed LokLF; dsUnz
eksMd xkao

izfrfyih %&
1- Jheku eq[; fpfdRlk ,oa LokLF; vf/kdkjh egksn; dksVkA
2- Jheku Cykd eq[; fpfdRlk vf/kdkjh pspV%&[kkSjkckn A

dk;kZy; fpfdRlk vf/kdkjh izHkkjh

izkFkfed LokLF; dsUnz eksMd xkao
ftyk dksVk ¼jkt-½
dzekad /ih,plh/ fnukad

Self Certificate

I Dr. Giriraj Agarwal & MOIC S/o Sh. Shri Hemraj Agarwal Age ….. years, R/o … Kota (Raj)
solemnly affirm and declare on oath as under:-

1. That I am responsible for establishing the Health Care Facility/ service named PHC
Morak Gaon, block – Chechat, Teh: Ramganjamndi, Dist: Kota (Raj).

2 That Dr. Giriraj Agarwal & MOIC authorized to sign the consent application form and

other documents/ enclosures of the applications related with this project.

3 That the bed capacity of the HCF is 0 BEDS therefore feasibility report is not required.

4 That no ground water will be abstracted without prior permission from CGWA.
 5 That bed capacity of the HCF is 0 Beds therefore details of built up area not required.

Mk0 fxfjjkt vxzoky

fpfdRlk vf/kdkjh izHkkjh
izkFkfed LokLF; dsUnz
eksMd xkao

dk;kZy; fpfdRlk vf/kdkjh izHkkjh

izkFkfed LokLF; dsUnz eksMd xkao
ftyk dksVk ¼jkt-½
dzekad /ih,plh/ fnukad

Self Certificate

I Dr. Giriraj Agarwal & MOIC S/o Sh. Shri Hemraj Agarwal Age ….. years, R/o
… Kota (Raj) solemnly affirm and declare on oath as under:-
1 That I am responsible for establishing the Health Care Facility/ service named PHC
Morak Gaon, block – Chechat, Teh: Ramganjamndi, Dist: Kota (Raj).

2 That Dr. Giriraj Agarwal & MOIC authorized to sign the consent application
form and other documents/ enclosures of the applications related with this
project.

3 That the area of the premises of theHealth Care Facility/ service is

………….Sq meter.
4 That the total number of employees in the Health Care Facility/ service is 5.

5 That in case of any increase or change in consented product production

capacity , addition / modification/ alternation or charge in process or raw
material or project or discharge effluent / emission points in future, fresh
Consent to Establish and / or Consent to Operate shall be obtained.
6 That the quantity of trade and domestic effluent shall not exceed NIL & 5
KLD and respectively. The mode of disposal shall be …-.. (or trade effluent)
and Septic Tank & Soak Pit (For domestic effluent).
7 That there will be no effluent discharge from the premises (applicable only in the case of dry
units).

8. That all adequate measures for prevention, control, treatment and disposal
of water/
air pollution from the various processes/ activities have been established so
as to meet the prescribed standards as per the Environment (Protection)
Rules, 1986.
9. That adequate pollution control measures are taken to meet the prescribed
ambient noise standards.
10.That the ground water shall not be abstract to fulfill the water requirement
of the Health care facility / service therefore NOC from Central ground
water from (CGWA) for abstraction of ground water is not required.
11.The being Micro Enterprises drawing ground water less 10 KLD, the project
is exempted from seeking NOC for abstraction of ground water as per
provisions of the latest guidelines issued by CGWA dated 24.09.2020.
12.That the proposed project / activity, mines is not covered under schedule of
EIA Notification 1992.
13.That the proposed mines/ project is covered under EIA Notification 2006.
However it does not require clearance for National Board for Wild life. The
copy of obtained from concerned Deputy Conservator of forest is attached.
(Only for the project / industry / activity / mines covered under schedule of
EIA Notification 2006).NA
14.That the Health Care Facility/ service is not covered under any provision of
Manufacture Storage and Import of Hazardous Chemical Rules, 1989,
therefore preparation of Onsite / Offsite Emergency plan is not required.
15.That Provisions of Public Liability Insurance Act are not applicable on Health
Care

Facility/ service , therefore Policy under PLI Act is not required.

16. That all orders and directions issued by the Board from time to time, shall
be complied
With.

Mk0 fxfjjkt vxzoky

fpfdRlk vf/kdkjh izHkkjh
izkFkfed LokLF; dsUnz eksMd
xkao
 fpfdRlk vf/kdkjh izHkkjh
izkFkfed LokLF; dsUnz
eksMd xkao