1362013phụ lục 4

Ph lc 4

Ph lc 4.1

Mu vn bn ngh xc nhn vic thc hin n bo v mi trng chi tit

(Ban hnh km theo Thng t s 01 /2012/TT-BTNMT ngy 16 thng 3 nm 2012 ca B trng B Ti nguyn v Mi trng quy nh v lp, thm nh, ph duyt v kim tra, xc nhn vic thc hin n bo v mi trng chi tit; lp v ng k n bo v mi trng n gin)(1)

S:

V/v ngh kim tra, xc nhn vic thc hin n bo v mi trng chi titCNG HO X HI CH NGHA VIT NAM

c lp - T do - Hnh phc

(a danh), ngy thng nm

Knh gi: (2)

Chng ti l: (1), Ch c s ca c s (3) (sau y gi tt l C s), c (4) ph duyt n bo v mi trng chi tit ti Quyt nh s ngy thng nm

- a im thc hin c s:

- a ch lin h:

- in thoi: ; Fax: ; E-mail:

thc hin n bo v mi trng chi tit, gm c:

1

2

Theo quy nh ca Thng t s 01/2012/TT-BTNMT ngy 16 thng 3 nm 2012 ca B trng B Ti nguyn v Mi trng quy nh v lp, thm nh, ph duyt v kim tra, xc nhn vic thc hin n bo v mi trng chi tit; lp v ng k n bo v mi trng n gin, xin gi n qu (2) h s gm:

- Mt (01) bn sao quyt nh ph duyt km theo bn sao n bo v mi trng chi tit c (4) ph duyt;

- Nm (05) bn bo co kt qu thc hin n bo v mi trng chi tit ca c s;

- Ph lc (vi s lng bng vi s lng bn bo co kt qu thc hin n bo v mi trng chi tit) km theo bo co kt qu thc hin n bo v mi trng chi tit, bao gm cc bn sao ti liu sau (ty loi hnh c s m c th c mt s hoc tt c cc ti liu ny):

+ H s bn v hon cng cc cng trnh x l v bo v mi trng (trng hp cha c bn v hon cng, c th cung cp h s thit k k thut. Trng hp ch c h s thit k k thut, cn nu r thc hin ng nh h s thit k k thut hay khng. Nu c sai khc cn ch r);

+ Cc chng ch, chng nhn, cng nhn ca cc thit b x l mi trng ng b nhp khu hoc c thng mi ha (nu c); + Cc phiu ly mu v kt qu o c, phn tch mu vn hnh th nghim cc cng trnh x l cht thi;

+ Bin bn nghim thu cc cng trnh bo v mi trng hoc cc vn bn khc c lin quan n cc cng trnh, bin php bo v mi trng;

+ Hp ng thu gom, vn chuyn, x l cht thi rn thng thng vi n v c chc nng (i vi trng hp c s c pht sinh cht thi rn thng thng trong giai on vn hnh v khng c cng trnh x l cht thi rn thng thng);

+ S ng k ch ngun thi cht thi nguy hi; hp ng thu gom, vn chuyn, x l cht thi nguy hi vi n v c chc nng, km theo vn bn chng minh chc nng ca n v (i vi trng hp c s c pht sinh cht thi nguy hi trong giai on vn hnh v khng c cng trnh x l cht thi nguy hi);

+ Hp ng hoc bin bn tha thun v vic u ni vo h thng thu gom v x l nc thi (i vi trng hp c s nm trong khu sn xut, kinh doanh, dch v tp trung v c pht sinh nc thi trong giai on vn hnh);

+ Quyt nh ph duyt k hoch phng nga v ng ph s c trn du; vn bn chng nhn iu kin v phng chy cha chy cp cho c s (i vi trng hp c s thuc i tng phi c cc loi vn bn ny theo quy nh ca php lut).Chng ti xin bo m v trung thc ca cc thng tin, s liu c a ra trong cc ti liu nu trn. Nu c g sai tri, chng ti xin hon ton chu trch nhim trc php lut ca nc Cng ho x hi ch ngha Vit Nam.

ngh qu (2) kim tra, xc nhn vic thc hin n bo v mi trng chi tit./.

Ni nhn:

- Nh trn;

- (6)

- Lu:...(5)

(K, ghi h tn, chc danh, ng du)

Ghi ch:

(1) Tn ch c s.

(2) Tn c quan c trch nhim kim tra, xc nhn.

(3) Tn y ca c s.

(4) C quan ph duyt n bo v mi trng chi tit.(5) i din c thm quyn ca ch c s.

(6) Ni nhn khc (nu c).

Ph lc 4.2

Mu bo co kt qu vic thc hin n bo v mi trng chi tit

(Ban hnh km theo Thng t s 01 /2012/TT-BTNMT ngy 16 thng 3 nm 2012 ca B trng B Ti nguyn v Mi trng quy nh v lp, thm nh, ph duyt v kim tra, xc nhn vic thc hin n bo v mi trng chi tit; lp v ng k n bo v mi trng n gin) (1)

S: /..

V/v bo co v ngh xc nhn hon thnh vic thc hin n bo v mi trng chi titCNG HO X HI CH NGHA VIT NAM

c lp T do Hnh phc


Knh gi: (2)

(1) xin bo co kt qu thc hin n bo v mi trng chi tit ca (3) (hoc giai on ca (3)) theo k hoch xy dng v vn hnh th nghim c ra trong n bo v mi trng chi tit, c th nh sau:

1. V tr ca (3) : ...2. a ch v phng tin lin h ca (1) :

- a ch lin h theo bu in:


3. Kt qu vn hnh th nghim

3.1. Cc cng trnh x l ton phn

3.1.1. Cng trnh xy dng tng th

3.1.2. Cng trnh xy dng theo tng giai on/m-un (nu c)3.2. Cc cng trnh x l trung gian (nu c)

3.2.1. Cng trnh xy dng tng th

3.2.2. Cng trnh xy dng theo tng giai on/m-un (nu c)

Yu cu:

1. i vi vic th nghim x l kh thi, nc thi:

- Ch dn r: Tn v a ch ca n v thc hin vic o c, ly mu, phn tch mu; phng php o c, ly mu, phn tch mu; thit b o c, ly mu, phn tch mu trong cc ln th nghim.

- Kt qu th nghim ca tng cng trnh (ton phn hoc trung gian) c trnh by theo bng sau:

Thng sn v tnhTrc khi x lSau khi x lTheo QCVN

12345

Th nghim ln 1: Ngy thng nm ; Tng lng/Lu lng .

A

B

.


A

B

.


A

B

.

2. i vi vic th nghim x l cht thi rn thng thng, cht thi nguy hi:

- Trng hp t x l: M t quy trnh qun l (thu gom, vn chuyn, lu gi, x l); bin php, phng tin, tin nghi s dng trong tng cng on ca quy trnh qun l.

- Trng hp thu x l: M t cc bin php, phng tin, tin nghi thu gom v lu gi tm thi; tn v a ch ca n v x l thu; bin php, phng tin thu gom v vn chuyn ca n v x l thu; tn sut thu gom ca n v x l thu.

4. Nhng thay i so vi k hoch ra trong n bo v mi trng chi tit (nu c)

5. nh gi kt qu th nghim

- nh gi v tin cy, mc t c v tnh n nh ca kt qu th nghim x l kh thi, x l nc thi.

- nh gi v mc tun th quy nh ca cc bin php qun l cht thi rn thng thng v cht thi nguy hi.

6. H s km theo bo co

Chng ti xin gi nhng h s, ti liu c lin quan c ng thnh tp km theo bo co ny.

7. Cam kt v ngh

Chng ti cam kt rng nhng thng tin, s liu nu trn l ng s thc; nu c g sai tri, s phi hon ton chu trch nhim trc php lut.

ngh (2) kim tra v xc nhn chng ti a cng trnh vo vn hnh chnh thc./.

Ni nhn:

- Nh trn;

- (5)

- Lu: (4)


Ghi ch:(1) Tn c quan/doanh nghip ch c s.

(2) Tn c quan c trch nhim cp giy xc nhn hon thnh.

(3) Tn y ca c s.

(4) i din c thm quyn ca c quan/doanh nghip ch c s.


Ph lc 4.3

Mu bo co kt qu vic thc hin n bo v mi trng chi tit (i vi c s quy nh ti im e khon 1 iu 3 Thng t ny v khai thc khong sn)(Ban hnh km theo Thng t s 01 /2012/TT-BTNMT ngy 16 thng 3 nm 2012 ca B trng B Ti nguyn v Mi trng quy nh v lp, thm nh, ph duyt v kim tra, xc nhn vic thc hin n bo v mi trng chi tit; lp v ng k n bo v mi trng n gin) (1)

S: /..

V/v bo co kt qu hon thnh hng mc cng trnh qun l, x l cht thi v cng trnh lin quan n bo v mi trngCNG HO X HI CH NGHA VIT NAM

c lp T do Hnh phc


Knh gi: (2)

(1) xin bo co kt qu hon thnh xy dng cc cng trnh qun l, x l cht thi v cng trnh c lin quan n bo v mi trng phc v cho giai on khai thc khong sn ca (3) theo k hoch v ni dung c ra trong n bo v mi trng chi tit, c th nh sau:




3. Hng mc cng trnh xy dng xong

TTHng mc M t

123

Cng trnh qun l, x l cht thi

1Cng trnh x l nc thi

2Cng trnh x l kh thi

3Ni lu gi, trung chuyn cht thi rn thng thng

4Ni lu gi, trung chuyn cht thi nguy hi

5Cng trnh chng n, rung

6Cng trnh khc ..

..

Cng trnh c lin quan n bo v mi trng

1ng giao thng ni b m

2ng giao thng ngoi m do c s t xy dng

3H thng thot nc m

4H thng bi thi trong, bi thi ngoi

5Kho thuc n

6Kho ha cht

7H thng dung dch khoan (trong khai thc du kh, nc ngm)

8H thng chng phun, chng pht (trong khai thc du kh)

9H thng ng ph s c trn du (trong khai thc du kh)

10Hng mc khc ..

Yu cu: Phi c s tng mt bng ch dn v tr tng hng mc cng trnh vi ch gii r rng.



5. Cam kt v ngh


ngh (2) kim tra v xc nhn chng ti a cng trnh vo hot ng./.

Ni nhn:

- Nh trn;

- (5)

- Lu: (4)




(3) Tn y ca c s.



Ph lc 4.4

Mu bo co kt qu vic thc hin n bo v mi trng chi tit (i vi c s quy nh ti im e khon 1 iu 3 Thng t ny c h cha nc)(Ban hnh km theo Thng t s 01 /2012/TT-BTNMT ngy 16 thng 3 nm 2012 ca B trng B Ti nguyn v Mi trng quy nh v lp, thm nh, ph duyt v kim tra, xc nhn vic thc hin n bo v mi trng chi tit; lp v ng k n bo v mi trng n gin) (1)

S: /..

V/v bo co v vic thu dn lng h v xy dng cc bin php bo v mi trngCNG HO X HI CH NGHA VIT NAM

c lp T do Hnh phc


Knh gi: (2)

(1) xin bo co kt qu hon thnh vic thu dn lng h v xy dng bin php bo v mi trng (nu c) ca (3) theo k hoch v ni dung c ra trong n bo v mi trng chi tit, c th nh sau:




3. Kt qu thu dn lng hTTHng mc thu dnn v tnhKhi lng, s lngHnh thc, cch thc tin hnhMc hon thnh so vi k hoch hoc yu cu t raGhi ch

1234567

1Thm thc vt (din tch, sinh khi, cy c g)

2Nh

3M m

4Cng trnh vn ha, tn gio, tn ngng (tn c th tng cng trnh)

5Khong sn khai thc tn thu (tn c th tng loi)

6Cng trnh sn xut, kinh doanh, dch v (tn c th tng cng trnh)

7Hng mc khc

4. Nhng hng mc khng th thu dn c (nu c)

- Tn hng mc khng th thu dn c

- L do khng th thu dn c

- Bin php x l hoc kin ngh bin php x l

5. Cc bin php bo v mi trng (nu c)



7. Cam kt v ngh


ngh (2) kim tra v xc nhn chng ti a cng trnh h cha vo tch nc./.

Ni nhn:

- Nh trn;

- (5)

- Lu: (4)




(3) Tn y ca c s.



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1362013phụ lục 4

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