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EIA Request Form
Organization Details
Organization name*
Contract No. (if exist)*
City or Zone* District name*
Mail Box*
Telephone no.* Fax no.*
E-mail
Person in Charge Information:
Person in charge*
Job Title:*
Extension no. Mobile no.*
E-mail*
EIA Request Details :
Subject of the study*
Facility Activity*
Facility Location
North:   
South:  
East:     
West:    
Facility Kuroki * only gif or jpg images allowed
Distance from residential area m2
Facility Area m2
Area photos (optional) only gif or jpg images allowed
Facility classification environmentally
Green areas m2
Material Safety Data Sheets (MSDS), (if exist) only word or PDF documents allowed
Pollution Points (Sources)
Production Power
Manpower
Shifts
Production lines description * only word or PDF files allowed
Type of Fuel used
Electricity Consumption
NO. of Fuel Tanks
Fire alarm system Yes No
Water consumption (Irrigation – drinking – Waste water)
Water Tanks Description No.       
Volume    Litter
Waste Management Contractors
* Requeired fields