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Contoh Permohonan Izin Tps b3

This document is a request for a permit to store and/or collect hazardous waste (B3 waste) submitted to the Regent of Lumajang. It includes information about the applicant such as their name, address, and contact details as well as details about the company. It also lists the types of permits already obtained by the company and provides a table outlining the minimum data requirements that must be included in the permit application attachment, such as the waste collection location, types and quantities of waste, waste characterization, and waste storage and transportation plans. The applicant signs the request and provides their name and company stamp.

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burhan yusuf
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95 views2 pages

Contoh Permohonan Izin Tps b3

This document is a request for a permit to store and/or collect hazardous waste (B3 waste) submitted to the Regent of Lumajang. It includes information about the applicant such as their name, address, and contact details as well as details about the company. It also lists the types of permits already obtained by the company and provides a table outlining the minimum data requirements that must be included in the permit application attachment, such as the waste collection location, types and quantities of waste, waste characterization, and waste storage and transportation plans. The applicant signs the request and provides their name and company stamp.

Uploaded by

burhan yusuf
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
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Nomor : ………… Kepada Yth:

Lampiran : ………… Bupati Lumajang


Perihal :Permohonan Izin Penyimpanan/ Cq. Kepala Dinas Lingkungan Hidup
Pengumpulan Limbah B3. Kabupaten Lumajang
di-
Tempat

Dengan ini kami mengajukan permohonan izin penyimpanan dan/atau


pengumpulan limbah B3 dengan data-data sebagai berikut:

A. Keterangan tentang pemohon


1. Nama Pemohon : ……………………………………………………
2. Alamat : ……………………………………………………
……………….............................................
……………………Kode Pos : (………………..)
3. Nomor Telp/Fax : (…….)…………../(…….)………………..........
4. Alamat e-mail : ……………………………….........................

B. Keterangan tentang perusahaan


1. Nama Perusahaan : …………………………………………………………………
………
2. Alamat : …………………………………………………………………
………
…………………………………………………………………
………
.................................... Kode Pos : (……..………..)
3. Nomor Telp/Fax : (…..….)………….….. / (…..….)………….…..
4. Jenis Usaha : ………………………………………
5. Nomor/ Tanggal Akte :
Pendirian ………………………………………
6. NPWP : ………………………………………
Jenis izin No Persetujuan / Izin
7. Izin-izin yang : 1. AMDAL/UKL/UPL ……………………………
diperoleh 2. IMB ……………………………
3. Izin Lokasi ……………………………
4. SIUP ……………………………
5. HO
6. ……………….........

1
C. Lampiran permohonan izin
No DATA MINIMAL YANG HARUS DILAMPIRKAN PY PK KETERANGAN
1. Keterangan tentang lokasi (nama
 
tempat/letak, luas, titik koordinat)
2. Jenis-jenis limbah yang akan dikelola  
3. Jumlah limbah B3 (untuk perjenis limbah)
 
yang akan dikelola
4. Karakteristik per jenis limbah B3 yang akan
 
dikelola
5. Tata letak penempatan limbah di tempat
 
penyimpanan sementara
6. Desain konstruksi tempat penyimpanan 
7. Lay out kegiatan  
8. Uraian tentang proses pengumpulan dan
perpindahan limbah (asal limbah dan titik 
akhir perjalanan limbah)
9. Surat kesepakatan antara penghasil/
pengumpul dengan pengolah/ pemanfaat/  
penimbun limbah
10. Uraian tentang pengelolaan pasca

pengumpulan
11. Perlengkapan sistem tanggap darurat  
12. Tata letak saluran drainase  
13. Lingkup area kegiatan pengumpulan **** 

Catatan:
1. Syarat minimal lampiran tersebut tetap memperhatikan dan menyesuaikan kondisi
pengelolaan limbah B3 yang ada.
2. PY = Kegiatan penyimpanan; PK = Kegiatan pengumpulan;

.............................................., .........

Nama, tanda tangan pemohon dan stempel


perusahaan,

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

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