FORM-I (See rule 4)

Return regarding Water consumed during the month of ________________

Name and Purpose for Reading at Reading at the Quantity of water If the meter Qauntitity Remarks (*)Address of which water the beginning end of the last consumed in water out of of waterthe consumer consumed of the first day of calendar Kilo litres order the monthly qualifying

day of the month under average consump- for rebatecalendar month report tion of water for accordingunder report the previous 3 to the

months of working assesseeperiod

1. 2. 3. 4. 5. 6. 7.______________________________________________________________________________________________________________________________________________________________

1. Industrial cooling i) from Municipal waterSpraying in mine supply mainsPits or boiler ii) from well/tube wellFeed. iii) from canal

iv) from riverv) from any other source

2. Domestic i) from Municipal waterpurpose supply mains

ii) from well/tube well iii) from canal

iv) from river v) from any other source

3. Processing i) from Municipal waterWhereby water supply mainsgets polluted & ii) from well/tube wellthe pollutants iii) from canal

are easily bio- iv) from riverdegradable v) from any other source

4. Processing i) from Municipal waterWhereby water supply mainsgets polluted & ii) from well/tube wellthe pollutants iii) from canal

are not easily iv) from riverbio-degradable v) from any other source

and are toxic

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

Signature of the consumer Name Address

ANNEXURE TO FORM 1

Report of Analysis of treated effluent showing the performance of treatment plant-For the month of __________

Sample collected on ………………. Sample tested on ………………….. By the laboratories…………………

Sr.No. Polluting parameters as Maximum Concentration Date on whichmentioned in the permissible limits or of range of _________________________________________condition imposed ranges allowed as parameters as There was break On which underunder consent granted per consent per report down or failure performance wasunder section 25/26 of conditions. of the plant noticedthe Water (Prevention and Control of Pollution) Act, 1974.

1 2 3 4 5 6

Signature……………………… Date…………………………… Name…………………………. Address……………………….