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521,/1000

194788
AWAL, 'I'APAK (PA!,)

PERMOHONAN

SENARAI

Sctiap permohonan PAT perl u mengemukalcan


MakIumat yang tidak Jengkap akan

sei)erli eli

pcrmohonan tidak

Butir-Butir Yang MEST1 Dikemukakan 01eh Pernobon:


Perkara
PAT (1engkap bertaip) beserta 'Covering

Plan', 'Site Plan' kilang dan pelan gunatanab


1 km radius

NOTA PENTING!

Setiap perrnobonan perlu dij


Silang tandakan (I)
permononan,

Binding' )
yang

semasa

eli

Bernml

Deriu

f.

f',t.~

BORANG AS PAT.
FORM AS PAT

BORANG PENAPISAN AWAL UNTUK PEMBINAAN KILANG BARU

PRELIMINARY SCREENING FORM T!-IE ESTABLISHNIENT

OF NEVV FACTORY

JABATAN ALAM SEKITAR

KEMENTERIAN SAINS, TEKNOLOGI DAN ALAM SEKlTAR

ARAS 3 - i, BLOCK C4

PUSAT PENTADBIRAN KERAJAAN PERSEKUTUAN

62662 PUTRAjA YA

TEL.: 03 - 88858200

FAKS: 03 - 8888998i

BORANG PENAPISAN AWAL UNTUK f'f:.MBINAAN KIIA,"!G BARLJ

PRELIM/NAP Y SCI?UNING For?!'v/ fOR nit FSIIIUllSIlMfNT

OF NEW FACiONV

1.

2,

Nama pemilik/Lembaga
Name of owner/Board of Directors:

3.

Alamat Ibu Pejabat:


Address of Head Office:

Telefon
Telephone:

4.

AJamat surat menyurat:


Address of correspondence:

5.

(i)

i\) ama Pemohon:


Name of Applicant:

(ii)

lawatan Pemohon:

Designation of Applicant:

(ii i)

Alamat Pemohon:
Address of Applicant:

Telefon ___,_,
Telephone:
6.

Nama dan
Perunding
Name and
Appointed

Faks: ___"________'~,__,,~,,

Fax

----,--,~,-,-,---,

~---'''---,,-----

---,~,,,-,~~~-,

Faks: ___,,,_,,,_,,,_,__ ~._


Fax

Alamat
Yang Dilantik:
Address of
Consultant:

Nama Pengurus KHang:


Name of Factory Manager:
(i)

Alamat Ki
Address of Factory:
-'-'-~'-'--~'''--~'----~----'~'--'~'-'

Telefon _ _ _ _ _ __
Telephone:

Faks:,_________
Fax

AS P!\ I

Garis Li

CeliiS

Latitude:

Longillle/e:
kkan keciuciu(1n kil,lng, kawilsan pCfunlilh;1I1, illl1l',lIi/suligai
1 km jcjari dari
k kil'lIlg.

*Kembarkan satu
lain-lain penggunaan
Attach a site plan
the
within 7 km radius of the site.

resie/enlinl area, vViller

Is the

proposed site situated in a

(111(1 ollieI' lalli/use

indllstrial zone (,Sidle?

Ya
Yes

Tic]flk
.No

Kalau va, berikcn nama kawasan


If yes, specify the name of the

(i)

----(ii)

Sila

~--------

lcrscbul scrtil bukti mcngcflidllYi1.


eslate

and

..

tersebut clan senakan saliran sural kcluiUS(1f1 syar(11 [(1I1ah.


and allaciJ a copy of the approvallctter for Inl1(} conversioll.

tidak, sila terangkan


If not, briefly describe the

sijil pendaftaran syarikat

Please attach registration certificate of company

12.

(il

Senarai Bahan-Bahan Mentah Yang


List Raw Materials Used
Perkara/Nama

nakan
Unit l<uantiti

Kuantiti

Unit of

Ian
Per Month

------

13,

cli1/l

tapak cadangan terletak cii clalam kiiwaS(11l pClinciustl-iiln Yfll1g d iWilfl;111I1 <

10.

11.

BUllIl"

(ii)

~-

--

....

Senarai Bahan-Bahan Kimia Yang 0


List of Raw Chemicals Used

Nama
Name

Unit Kuantiti
Unit of

Kuantiti

Ian
Per Month

!\S Pin

uaran:

14.

Nama
Name

(i)

l(u,1I1[i:i Scbulal1
C)u<lntity Per Month

Unit /(uantiti

Unit or

Purata
Average

Maksirnum
Maxi/nulII

(ii) Masa

Purala
Average

Mabinlllill
A1aximuln

(i i i) Bilangan Ilari Operasi


Days or Operation

Semi
Per

Syif Sehari:
or Shifts Per

---~-'"~

Sebulan
Per ivlonth

Setahun
Per Year

16.

Terangkan
Describe in

seeara terperinei semua proses pengel u ara Il dan


rajah a lira n
all
processes and attach relevant flow diagrams.

---------.-----~---

17.

I(egunaan Air
Water

... -

- - -....

Punea
Source

(i)

Air ,Iviinum:
Water:

(ii)

Air Pr'oses:
Process Water:

..

....

_--

(iii) Air Bekalan Da


Feed Water:
(iv)
(v)

k:
Lain-Lain:
Others:

Elektrik

Alat-Alat

- - _...._----_._-
- - _ ........__ ..._-_..,._--

Alat-Alat

Bilangan
Quantity

(i)

Dandang:
[Jaffer:

(ii)

Dapur:
Cookel/Oven:

Hahanapi
of Fuel

(f i i)

Generator:
(iv) insinerator:
Incinerator:
(v)
(nyatakan)
Others (specify):

20.

Dal'i rajah a I iran bagi sernu a proses pengel Llaral1, 511a tll njukkan tempat pe lepasan pencemaran dan
From the (Iowdiagrarns
show the
of emission
and
of pollutants
(i)

Tempat
Points of Emmision/

..

1.

(i)

(iii)

Jenisnya
Types of
Pollutants

I<uantiti
Quantity

~~---

AcJakah
aan tuan
Do the processes

Ya
Yes

(i i)

(ii)

Kalau ya , sebutkan
If yes, specify the

buangan

I?

Tidak
No
h, pelupusan dan j
of disposal and also

site

------------ -------------_._--

..

--

;\SI'!\T
(i i i)

hunyi hising
in [he (ae/or y.

Noise

I(Uilsa I<u cia

Norse Pmvcr

~~~~--~-------

MAlKLUMAT flVM!BiAHA'I\J

ADDITfONALIN:Fo,RM'ATJON
22.

berikut hendaklah disci-lakan


The foffowing should
provided as attachments.
(j)

lampiran.

Pelan susunatur
Plan

(i j) /\1 at kawal an liang dicadangkan d


kawalan yang akan diambil bagi penccrna ran
air,
bunyi bising, bau scrla buangan
lerjadual, Sila kClTlukakan bersarna
dokumen-dokumen/katalog-katalog/buti
r penerangan yang
Proposed control
to be taken to
air, waler,
odour, solid waste and
and explanatory notes that are
toxic waste pu/lution, Please submit

yang bertandatangan di bawah ini, mengaku bahawa scgala maklumat yang di


benar clan betul sepanjang pengetahuan dan kepercayaan saya.

dalam borang inj adalah

I, the undersigned, certify that the information given in this application form is to the best of my knowledge and
belief true and correct.
Tarikh: _______
Date

Tandatangan Pegawai Pelapor:


Signature of Reporting Official
Nama Pen uh: ____________~~_~_~ _____________~_~________
Full Name

Designation

Ada
Yes

Perb'ra
Subject

Lengkap
Complete

n Ill;)ksuci

PA

the purpose of the applicalion.

Borang AS P;-\T diisi

lellgkap.

Form AS PA T completely filled.

Tiada
lengkap
Incomplete

No