FORM II

(See Rule 10)

APPLICATION FOR AUTHORIZATION OR RENEWEL OF AUTHORISATION
(To be submitted by occupier of Health Care Facility or Common Bio-Medical Waste Treatment
Facility)

To ,
The Member Secretary,
Uttar Pradesh Pollution Control Board

1 Particulars of the applicant:

i) Name of the applicant : PIYUSH JAIN
Designation :
ii) Name of the Institution : JAIN DENTAL CARE CENTRE
Address for correspondence : KALAGARH ROAD, TEACHERS COLONY,
DHAMPUR, DISTT.-BIJNOR
,BIJNOR,246761
Landline phone No : -
Mobile No. : 9412136759
E-mail Id : drpiyushjain04@rediffmail.com
2 Activity for which authorisation is sought:
Generation, segregation,Collection,Storage,Packaging
3 i) Authorization now Applied For : : Fresh
3 ii) Previous Authorization Details :
iii) Status of CTE/CTO-latest consent type, : No
issued date and validity date
iv) GPS Coordinates- Lat/Lon of the location of Latitude: (N Decimal degrees)
applicant facility(In decimal degress with 6 Longitude: (E Decimal degrees)
decimals)
4 i) BMW Facility Type : HCF
ii) BMW Facility Status : HCF-Common Facility Member
iii) Address of the location of Health Care Facility : KALAGARH ROAD, TEACHERS COLONY,
or CBMWTF DHAMPUR, DISTT.-BIJNOR
,BIJNOR,246761

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iv) CBMWTF-Office and location address of : M/s Synergy Waste Management (p) Ltd. 011-
treatment and disposal 26933371 Subharti Medical College, Subharti
Puram, Meerut. Mob. No.9212310082
/
M/s Synergy Waste Management (p) Ltd. 011-
26933371 Subharti Medical College, Subharti
Puram, Meerut. Mob. No.9212310082
5) Details of HCF
i) Medical Treatment Facility provided to : 02
Outpatients
ii) Medical Treatment Facility provided to : 00
Inpatients
iii) No of Beds : 00
iv) For Non bedded Hospital (Specify) : DENTAL CARE
v) Total number of inpatients & outpatients treated :
per month in the HCF
vii) Quantity of BMW handled, treated or disposed:
Catego Type of Waste Quantity Method of Treatment and
ry Generated or Disposal as per Schedule-I
collected in
Kg/day
Yellow a) Human Anatomical Incineration
Waste
b) Animal Anatomical Incineration
Waste
c) Soiled Waste Incineration
d)Expired or Discarded Incineration
Medicines
e)Chemical Solid Waste Incineration
f) Chemical Liquid Waste Onsite ETP to treat and conform to
the discharge standards
g)Discarded linen, Disinfection followed by
mattresses, beddings Incineration
contaminated with blood
or body fluid
h) Microbiology, Sterilisation followed by
Biotechnology and other Incineration
clinical laboratory waste
Red Contaminated waste Autoclaving followed by shredding.
(Recyclable) Treated waste to be sent to
Authorised recyclers or for energy
recovery or plastic to Diesel or fuel
oil or for road making
White( Waste sharps including Autoclaving followed by shredding.
Translu Metals Treated waste to be sent to Iron
cent) foundries or sanitary landfill or
designated concrete waste sharp pit.

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 Blue Glassware Disinfection or Autoclaving or
microwaving or hydroclaving and
then sent for recycling
Metallic Body Implants
Total Kg/Day
6i) Mode of Transportation of BMW : Common Facility Vehicle
ii) Details of Treatment equipments available for treatment of BMW:
Sl Treatment equipment No of units Type and capacity of each unit
No
1 Incinerators
2 Plasma Pyrolysis
3 Autoclaves
4 Microwave
5 Hydroclave
6 Shredders
7 Needle tip cutter or
destroyer
8 Sharp encapsulation or
Concrete pit
9 Deep burial pits
10 Chemical disinfection
11 Any other treatment
equipment
7 Details of directions or notices or legal : No
actions if any during the period of earlier
authorisation
8 Declaration
I do hereby declare that the statements made and information given above is true to the best of
my knowledge and belief and that I have not concealed any information.
I do also hereby undertake to provide any further information sought by the prescribed Authority
in relation to these rules and to fulfil any conditions stipulated by the prescribed Authority.

Date: 25/07/2022
Signature of the applicant
Name and Designation

Enclosures:
1. AGREEMENT
2. Letter
3. adhar