ANNEXURE TO FORM 1

Report of Analysis of Treated Effluent showing performance of the Treatment Plant for the Month of ...........................................
SAMPLE COLLECTED ON :
SL
NO.

Polluting parameters as mentioned in the

condition imposed under consent granted
under section 25/26 of the
water (prevention and Control of Pollution)
Act, 1974.
2

Encl : Original Analysis Report of Laboratory.

SAMPLE TESTED ON :
Maximum permissible limits
or ranges allowed as per
consent conditions

BY THE LABORATORIES :
Concentration of range of
parameters as per report

Signature
Date
Name
Address

:
:
:
:

Dates on which, there was

breakdown or failure of
the plant

On which under
performance was noticed

Form-1
See Rule- 4
Returns Regarding Water Consumed during the Month of
Name and address Purpose for which Water
of the consumer
consumed

Reading at the begining of

the first day of the calendar
month under report

Reading at the end

of the last day of
calendar month
under report

Industrial cooling, spraying in mine pits or boiler feed

i from Municipal Water supply mains.

ii from well tubewell.
iii from canal.
iv from river.
v from any other source.

Domestic purpose

i
ii
iii
iv

from Municipal Water supply mains.

from well Tubewell.
from cannal.
from any other source.

Processing whereby water gets polluted and

the pollutants are easily bio-degradable

i
ii
iii
iv
v

from Municipal Water supply mains.

from well tubewell.
from canal.
from river.
from any other source.

Processing whereby water gets polluted and

the pollutants are not easily bio-degradable and are toxic

i from Municipal Water supply mains.

ii from well tubewell.
iii from canal.
iv from river.
v from any other source.

Quantity of water If the meter was out of

consumed in
order, the monthly
kilo-litres
average consumption
of water for the previous
3 months of the
working period
5

Quantity of water
Remarks (*)
qualifying for rebate
according to the
assessee

(*) for claiming rebate under Col.7 of the assessee shall indicate in this column the analytical and other reports annexed to this returns in support of this claim.
Signature of the Consumer

Name

Address