1.Particulars of the applicant
i. Name of the authorized person (occupier/operator) :
ii. Name and address of institution:	,

2. Category of waste (as per schedule-I of the rule) generated and quantity for the Year of: -

Month-Year	Yellow	Red	Blue	White Translucent
	gms	gms	gms	gms
Total	gms	gms	gms	gms
Grand Total	gms
Monthly Average	gms	gms	gms	gms

3. Brief details of the treatment facility:
In case off-site facility:
i. Name of the operator:
ii. Name and address of the facility:	,

4. Category-wise quantity of waste treated:
i. Incineration/Burial (Yellow bag):	Nos
ii. Autoclave/Microwave
a) Red Bag:	Nos
b) Blue bag:	Nos
c) White Translucent bag:	Nos

5. Mode of treatment with details:

Waste is handed over to the authorized disposal agency (i.e. )

6. Any other information:

7. Certified that the above report is for the period from to

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Date :
Place :	Signature:
Designation : Head Medical Services
	Factory Medical Officer