APPENDIX – I (See paragraph – 6) FORM 1 (I) Basic ... - Seiaacg.org

10. Nearest railway station/airport along withDistance in kms.11. Nearest Town, city, District HeadquartersAlong with distance in kms.12. Village Panchayats, Zilla Parishad, MunicipalCorporation, Local body (complete postalAddress with telephone nos. to be given)MahasamundDistance – 20Km.MahasamundDistance – 20Km .Mahasamund13. Name of the applicant Smt. Kuleshwari Sahu14. Registered Address Shri Balak Ram SahuVill.-Achholi, The.-Mahasamund Distt.-mahasamund.15. Address for correspondence: ---Do---NameDesignation (Owner/Partner/CEO)AddressPin CodeE-mailSmt. Kuleshwari SahuOwnerShri Balak Ram SahuVill.-Achholi, The.-Mahasamund Distt.-mahasamund.Telephone No. 09617724523Fax No.16. Details of Alternative Sites examined, if any. Location ofthese sites should be shown on atopo sheet.17. Interlinked Projects --N.A.--Village-District-State1.2.3.18. Whether separate application of interlinkedProject has been submitted?--N.A.--19. If yes, date of submission --N.A.--2

20. If no, reason --N.A.--21. Whether the proposal involves approval / clearanceunder: if yes, Details of the sameand their status to be given.(a) The Forest (Conservation) Act, 1980?(b) The Wildlife (Protection) Act, 1972(c) The C.R.Z. Notification, 1991?No. These acts are notapplicable on theproposed site.22. Whether there is any Government Order/ Policy relevant/ --N.A.--relating to the site?23. Forest land involved (hectares) --N.A.--24. Whether there is any litigation pending against the projectand /or land in whichthe project is propose to be set up?(a) Name of the Court(b) Case No.(c) Orders/directions of the Court, if any and itsrelevance with the proposed project.No litigation either inpresent or in past.• Capacity corresponding to sectoral activity (such as production capacity for manufacturing,mining lease area and production capacity for mineral production, area for mineralexploration, length for linear transport infrastructure, generation capacity for powergeneration etc.,)(II)Activity1. Construction, operation or decommissioning of the Project involving actions,which will cause physical changes in the locality (topography, land use, changesin water bodies, etc.)S.No. Information/Checklist confirmation1.1 Permanent or temporary change in landuse, land cover or topography includingincrease in intensity of land use (withDetails thereof (withapproximate quantitiesYes/No /rates, wherever possible)with source of informationdataNo Land will be used formining, being excavation ofearth for building material.3

espect to local land use plan)1.2 Clearance of existing land, vegetationand buildings?Open Land, with no existingvegetation or building1.3 Creation of new land uses? No1.4 Pre-construction investigations e.g. borehouses, soil testing?No1.5 Construction works? No1.6 Demolition works? No1.7 Temporary sites used for constructionworks orhousing of construction workers?1.8 Above ground buildings, structures orearthworks including linear structures, cutand fill or excavations1.9 Underground works including mining ortunneling?NoYes Activity includesexcavation of earth andcrushing of minedlimestone for use asbuilding materialNo1.10 Reclamation works? No1.11 Dredging? No1.12 Offshore structures? No1.13 Production and manufacturingprocesses?1.14 Facilities for storage of goods ormaterials?1.15 Facilities for treatment or disposal of solidwaste or liquid effluents?1.16 Facilities for long term housing ofoperational workers?No Activity involves onlyexcavation and crushing ofmined limestone, no newgoods produced ormanufactured.No The crushed limestone willbe kept as is on the openland of the proposed site.No No solid or liquid wastegenerated.No Local labourers will beemployed1.17 New road, rail or sea traffic duringconstruction or operation?NoExisting approach road isto be used.4

1.18 New road, rail, air waterborne or othertransport infrastructure including new oraltered routes and stations, ports,airports etc?1.19 Closure or diversion of existing transportroutes or infrastructure leading tochanges in traffic movements?1.20 New or diverted transmission lines orpipelines?NoNoNo1.21 Impoundment, damming, culverting, Norealignment or other changes to thehydrology of watercourses or aquifers?1.22 Stream crossings? No1.23 Abstraction or transfers of water formground or surface waters?1.24 Changes in water bodies or the landsurface affecting drainage or run-off?NoNo1.25 Transport of personnel or materials for Noconstruction,operationordecommissioning?1.26 Long-term dismantling or Nodecommissioning or restoration works?1.27 Ongoing activity during decommissioning Nowhich could have an impact on theenvironment?1.28 Influx of people to an area in either No Local persons will betemporarily or permanently?employed1.29 Introduction of alien species? No1.30 Loss of native species or geneticdiversity?No1.31 Any other actions? No2. Use of Natural resources for construction or operation of the Project (such asland, water, materials or energy, especially any resources which are nonrenewableor in short supply):5

S.No. Information/checklist confirmation2.1 Land especially undeveloped oragricultural land (ha)Details thereof (withYes/No approximate quantities/rates, wherever possible)with source of informationdataYes Open land, which is notsuitable for agriculture2.2 Water (expected source & competing No No requirementusers) unit: KLD2.3 Minerals (MT) No No construction to be done2.4 Construction material – stone,aggregates, sand / soil (expected source– MT)NoNo construction to be done2.5 Forests and timber (source – MT) No No construction to be done2.6 Energy including electricity and fuels Yes As there is no need for(source, competing users) Unit: fuelconstruction(MT), energy (MW)2.7 Any other natural resources (useappropriate standard units)NoNo construction to be done3. Use, storage, transport, handling or production of substances or materials,which could be harmful to human health or the environment or raise concernsS.No. Information/Checklist confirmation Yes/No3.1 Use of substances or materials, which arehazardous (as per MSIHC rules) to humanhealth or the environment (flora, fauna,and water supplies)3.2 Changes in occurrence of disease oraffect disease vectors (e.g. insect or waterborne diseases)NoNoDetails thereof (withapproximate quantities/rates, wherever possible)with source of informationdata3.3 Affect the welfare of people e.g. bychanging living conditions?No3.4 Vulnerable groups of people who could be Noaffected by the project e.g. hospitalpatients, children, the elderly etc.,3.5 Any other causes No6

about actual or perceived risks to human health.4. Production of solid wastes during construction or operation or Decommissioning(MT/month)S.No. Information/Checklist confirmation Yes/No4.1 Spoil, overburden or mine wastes NoDetails thereof (withapproximate quantities/rates, wherever possible)with source of informationdata4.2 Municipal waste (domestic and orcommercial wastes)No4.3 Hazardous wastes (as per HazardousWaste Management Rules)No4.4 Other industrial process wastes No4.5 Surplus product No4.6 Sewage sludge or other sludge fromeffluent treatmentNo4.7 Construction or demolition wastes No4.8 Redundant machinery or equipment No4.9 Contaminated soils or other materials No4.10 Agricultural wastes No4.11 Other solid wastes No7

5. Release of pollutants or any hazardous, toxic or noxious substances to air (Kg/hr)S.No. Information/Checklist confirmation Yes/No5.1 Emissions from combustion of fossil fuelsfrom stationary or mobile sourcesNoDetails thereof (withapproximate quantities/rates, wherever possible)with source of informationdata5.2 Emissions from production processes No5.3 Emissions from materials handlingincluding storage or transport5.4 Emissions from construction activitiesincluding plant and equipmentNoNo5.5 Dust or odours from handling of materials Noincluding construction materials, sewageand waste5.6 Emissions from incineration of waste No5.7 Emissions from burning of waste in openair (e.g. slash materials, constructiondebris)No5.8 Emissions from any other sources No6. Generation of Noise and Vibration, and Emissions of Light and Heat:S.No.Information/Checklist confirmation6.1 From operation of equipment e.g.engines,ventilation plant, crushersYes/No Details thereof (withapproximate quantities/rates, wherever possible)with source of informationdata with source ofinformation dataNo As no engines will be used formining.8

6.2 From industrial or similar processes No6.3 From construction or demolition No6.4 From blasting or piling No6.5 From construction or operational traffic No6.6 From lighting or cooling systems No6.7 From any other sources No7. Risks of contamination of land or water from releases of pollutants into theground or into sewers, surface waters, groundwater, coastal waters or the sea:S.No. Information/Checklist confirmation Yes/No7.1 From handling, storage, use or spillage ofhazardous materialsNoDetails thereof (withapproximate quantities/rates, wherever possible)with source of informationdata7.2 From discharge of sewage or othereffluents to water or the land (expectedmode and place ofdischarge)No7.3 By deposition of pollutants emitted to airinto the land or into waterNo9

7.4 From any other sources No7.5 Is there a risk of long term build up ofpollutants in the environment from thesesources?No8. Risk of accidents during construction or operation of the Project, which couldaffect human health or the environmentS.No. Information/Checklist confirmation Yes/NoDetails thereof (withapproximate quantities/rates, wherever possible)with source of informationdata8.1 From explosions, spillages, fires etc fromstorage, handling, use or production ofhazardous substancesNoAs there will be no explosions.8.2 From any other causes No NA8.3 Could the project be affected by naturaldisasters causing environmental damage(e.g. floods, earthquakes, landslides,Cloudburst etc)?NoIt will be affected as the otherthings will be affected in thearea.9. Factors which should be considered (such as consequential development) whichcould lead to environmental effects or the potential for cumulative impacts withother existing or planned activities in the localityS. No. Information/Checklist confirmation Yes/No9.1 Lead to development of supporting.lities, ancillary development ordevelopment stimulated by the projectwhich could have impact on theenvironment e.g.:NoDetails thereof (withapproximate quantities/rates, wherever possible)with source of informationdata10

• Supporting infrastructure (roads, powersupply, waste or waste water treatment,etc.)• housing development• extractive industries• supply industries• other9.2 Lead to after-use of the site, which could Nohavean impact on the environment9.3 Set a precedent for later developments No9.4 Have cumulative effects due to proximityto other existing or planned projects withsimilar effectsNo(III)Environmental SensitivityS.No. Areas Name/IdentityAerial distance (within 15km.) Proposed projectlocation boundary1 Areas protected under internationalconventions, national or local legislationfor their ecological, landscape, culturalor other related value2 Areas which are important or sensitive forecological reasons - Wetlands,watercourses or other water bodies,coastal zone, biospheres, mountains,forests3 Areas used by protected, important orsensitive species of flora or fauna forbreeding, nesting, foraging, resting, overwintering, migrationNoNoNoLand is not near to any waterbodies.Open land with no vegetationor plants.4 Inland, coastal, marine or undergroundwatersNo11

5 State, National boundaries No6 Routes or facilities used by the public for Noaccessto recreation or other tourist, pilgrimareas7 Defence installations No8 Densely populated or built-up area No9 Areas occupied by sensitive man-madeland uses (hospitals, schools, places ofworship, community facilities)No10 Areas containing important, high qualityor scarce resources(ground water resources, surfaceresources, forestry, agriculture, fisheries,tourism, minerals)11 Areas already subjected to pollution orenvironmental damage. (those whereexisting legal environmental standardsare exceeded)12 Areas susceptible to natural hazard whichcould cause the project to presentenvironmental problems(earthquakes, subsidence, landslides,erosion, floodingor extreme or adverse climaticconditions)NoNoNo(IV)Proposed Terms of Reference for EIA studiesI here by given undertaking that the data and information given in the application andenclosure are true to the best of my knowledge and belief and I am aware that if any part of thedata and information submitted is found to be false or misleading at any stage, the project will berejected and clearance give, if any to the project will be revoked at our risk and cost.Date:Place:Signature of the applicantWith Name and Full Address(Project proponent / Authorised Signatory12

NOTE:1. The projects involving clearance under coastal Regulation zone Notification, 1991 shall submitwith the application a C.R.Z. map duly demarcated by one of the authorized agencies,showing the project activities, w.r.t. C.R.Z (at the stage of TOR) and the recommendations ofthe State coastal zone Management Authority (at the stage of EC). Simultaneous action shallalso be taken to obtain the requisite clearance under the provisions of the C.R.Z. Notification,1991 for the activities to be located in the CRZ.2. The projects to be located within 10 km of the National parks, sanctuaries, BiosphereReserves, Migratory corridors of wild Animals, the project proponent shall submit the map dulyauthenticated showing by chief wildlife warden showing these features vis-a-vis the projectlocation and the Recommendation or comments of the Chief Wildlife Warden 'thereon (at thestage of EC)."3. All correspondence with the Ministry of Environment &Forests including submission ofapplication for TOR/Environment Clearances, subsequent Clarifications, as may be requiredfrom time to time, participation in the EAC Meeting on behalf of the project proponent shall bemade by the authorized signatory only. The authorized signatory should also submit adocument in support of his claim of being an authorized signatory for the specific project.13

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