Kop Surat

Nomor : ………………………...............
Lampiran : ………………………...............
Perihal : Permohonan Persetujuan Teknis
Pengelolaan Limbah B3 Cair Kepada Yth.
Kepala Dinas Lingkungan Hidup
Kabupaten Lombok Timur
di
Selong

Dengan ini kami mengajukan permohonan Baru Rencana Teknis di Bidang Pengelolaan Limbah B3
untuk kegiatan Pengelolaan Limbah B3 Cair dengan data-data sebagai berikut :

A. Keterangan Tentang Pemohon

1. Nama Pemohon : ..........................................................................................

2. Jabatan : ..........................................................................................
3. Alamat : ..........................................................................................
..........................................................................................
..........................................................................................
4. Telp/Fak : ....................................................... ..................................
5. Alamat e-mail : ..........................................................................................

B. Keterangan Tentang Perusahaan

1. Nama Perusahaan : ...........................................................................................

2. Alamat Perusahaan : .........................................................................................
..........................................................................................
3. Alamat Lokasi : ..........................................................................................
Kegiatan .........................................................................................
.........................................................................................
4. No. Telp/ Fax : ..........................................................................................
5. Alamat e-mail : ...........................................................................................
6. Nomor Induk : ………………………………............................................
Berusaha (NIB
7. Nomor Pokok Wajib : ..........................................................................................
Pajak (NPWP)
8. Bidang Usaha : ...........................................................................................
/Kegiatan
9. Nama dan Nomor : ..........................................................................................
Telepon yang Bisa ..........................................................................................
Dihubungi

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PEMOHON

( .............................................. )
C. Identitas Pengurus Permohonan Persetujuan Teknis di Bidang Pengelolaan Limbah B3

1. Nama : ……………………………....................................................
2. Jabatan : ......................................................................................
3. Surat Kuasa : .......................................................................................
4. Alamat dan/atau : .......................................................................................
Domisili ......................................................................................
......................................................................................
.......................................................................................
......................................................................................
5. No. Telp/ Fax : ........................................... ...........................................
6. Alamat e-mail : ….………………………………..............................................

Demikian Dokumen ini kami ajukan Atas Perhatiannya kami sampaikan terima kasih.

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PEMOHON

( .............................................. )