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APPLICATION FORM FOR
STORAGE LICENSE
FORM-4
[See Rules 6(1)]
Received at
(place) on the
.. day of
month
..year
..
To,
The Collector
District -
Chhattisgarh
.
Sir,
I/We
.. Request
for the grant/renewal of temporary storage
permit/beneficiation/processing/coal washery/iron ore
crushing unit/ other crushing unit.
1. Name of Mineral
.
2. Quantity (Maximum
capacity to store at a time)
.
3. Period
.
.
4. Place
.
.
5. A sum of Rs.
. as
application fee payable under these rules has been
deposited vide challan No.
. dated
.at place
6. The required particulars
are given below :-
(i) Name of the
applicant with complete address
...
(ii) Is the
applicant is an Individual/Private Company/Public
Company/Firm or Association (Strike off whichever is not
applicable)
(iii) Profession or
nature of business of applicant
.
(iv) No Mining Dues
Certificate (Copy attached)
.
(v) If on the date
of application, the applicant does not hold any mineral
concession/license in the state furish an affidavit for
the same
.
(vi) Mineral/Ore or
its products, for which the applicant intend to, hold a
permit
..
(viii) Enclose the
certified copy of the map and latest revenue record of
the land intended to be used for storing
mineral/minerals or its products.
Where the applicant has not owned
the land, an affidavit to the effect that he/she has
obtained the surface right or the consent of the
owner
..
(ix) Any other
details that applicant desires to submit
.
Signature of the applicant
Name:
Address:
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