Article 1Every business and or activity is forbiden to dispose waste water containing radioactive to water or water source Article 2Regent or Mayor is forbid to publish wastewater disposal to water or water source permit that violate water quality standard and cause water pollution.Article 3(1) Every business and or activity that will dispose wastewater to water or water source must obtain written permission from Regent/Mayor(2) Permit application as referred to in article (1) based on the results of analytical study on environmental impact or study of environmental management efforts and environmetal monitoring efforts.(3) Permit requirements of wastewater disposal to water or watersource must comply with the requirements referred in Article 38 paragraph (2) of Government Regulation No. 82 2001 on Water Quality Management and Water Pollution Control Article 4(1) Application for permission to dispose wastewater to water or water sources must be completed by data and information using form as attached in this decree(2) Data and information referred in paragraph (1) above is one of the requirements for wastewater disposal to water and water source permission.(3) In addition to the requirements referred to in paragraph (2) above, the permission application must be completed with:a. Study result document on wastewater disposal to water and or water source;b. Result of environmental management monitoring on the previous monthc. Other documents related with the filing of the form attached in this decreeArticle 5The study referred to in Article 4 paragraph (3) is based on:a. Industry type and business type and or activity concerned;b. Environmental baseline;c. Amout of wastewater being disposedd. Load capacity of water pollution as defined Minister of State for Environmental Decree No. 110 2003 on Guidelines for Determination of Load Carrying Capacity of Water Pollution in Water Source.

Article 6Regent/Mayor must indicate in the wastewater disposal permit all the obligations and prohibitions for business and or activity as stated in Government Regulation No. 82 2001 about Water Quality Management and Water Pollution Control.Article 7Wastewater disposal permit to land controlled by its own legislation. Article 8The decree takes effect on the date specified.

Defined in Jakarta, 27 June 2003Minister of EnvironmentNabiel Makarim, MPA, CPO

A copy of the originalMinistry of Environment Environment Policy and Institutional Field Deputy I,Hoetomo, MPA

Attachement:Minister of Environment No. 111 2003, 27 June, 2003Wastewater Disposal to Surface Water Permission ApplicationNama Usaha dan atau Kegiatan (Business Name or Activity)

Jenis Industri (Industry Type):Baterai Kering (Dry Battery)Bir (Beer)Cat (Paint)Etanol (Ethanol)Farmasi (Pharmacy)Gula (Sugar) Karet (Rubber)Kayu Lapis (Plywood)Minuman ringan (Soft Drink)Minyak Nabati (Vegetable Oil)Minyak Sawit (Palm Oil)MSG (MSG)Pelapisn Logam (Metal Coating)Pengilangan Minyak (Oil Refinery)Penyamakan Kulit (Tannery)Pestisida (Pesticide)Hotel (Hotel)Rumah Sakit (Hospital)Pulp & Paper (Pulp & Paper)Pupuk Urea (Urea Fertilizer)Sabun,detergen (Soap, detergent)Soda Kostik (Caustic Soda)Susu & Makanan (Milk and Food)Tapioka (Starch)Tekstil (Textile); etc..Jenis Kegiatan/ Usaha Lainnya (Activity Type/Other Activities):Penambangan (Mining)Kawasan Industri (Industry Region)Lainnya (etc)

Jenis permohonan (Application Type):Baru (New) Perpanjangan (Renewal)

II. GENERAL INFORMATION

1. Lokasi Kegiatan/ Usaha (Location of Activity/Business)a. Jalan/ Desa/ Kelurahan (Street/Village/):b. Kecamatan (Subdistrict) :c. Kabupaten/ Kodya (District/Municipality) :d. Provinsi (Province) :e. Kode Pos (Zip Code) :f. Telepon (Phone) :g. Facsimile (Facsimile):

2. General Manager :

3. Kontak Person (Contact Person)a. Nama (Name) :b. Jabatan (Position) :c. Telepon (Phone) :

4. Lokasi Kantor Pusat (Head Office Location) (If different from the location of activity/business)a. Jalan/ Desa/ Kelurahan (Street/Village/): :b. Kecamatan (Subdistrict) :c. Kabupaten/ Kodya (District/Municipality) :d. Provinsi (Province) (Zip Code) :e. Kode Pos (Zip Code) :f. Telepon (Phone) :g. Facsimile (Facsimile): :

5. Jika kegiatan/ usaha merupakan bagian dari suatu group perusahaan (If Activity or Business is part of Company Group):a. Nama Group (Group Name) :b. Alamat (jalan/ desa/ kel.) (Address):c. Kecamatan (Subdisctrict) :d. Kabupaten/ Kodya (District/Municipality) :e. Provinsi (Province) :f. Kode Pos (Zip Code) :

III. PERMIT INFORMATION

State the number and agency issuing permit :a. Izin Usaha (Business License)Nomor : NumberPemberi Izin (Permit Issuer ) :b.Izin Mendirikan Bangunan (IMB) Nomor (Building Permit Number) :Pemberi Izin (Permit Issuer) :d. Izin Undang-undang Gangguan (HO) Nuisance Act Permits Number Pemberi Izin (Permit Issuer) :d. Izin Lokasi Nomor (Location Permit Number)Pemberi Izin (Permit Issuer): Izin Pengambilan Air (SIPA) (Water Intake Permit) Nama (Name) : Pemberi Izin (Permit Issuer):f. Izin Pembuangan Limbah Nomor (Waste Disposal Permit Number) :Pemberi Izin:

*) All permits mentioned above shoud be attached.

IV. PRODUCTION INFORMATION

*) For non-industrial activites, the following fields can be customized according to the activity.

1. Year of Operation 2. Total water need and source (m3/ month):a. PAM (Water Utility Company) b. Air Tanah (Groundwater) c. Sungai (River) d. Laut (Sea) e. Lainnya (Others)

3. Water Need (m3/ day) use for:a. Produksi (Production) b. Cooling water c. Domestik (Domestic) d. Lainnya (Others)

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Source (%)NoMaterial NameTrademarkFormDomesticImport4. Raw Material and Auxiliary *)

*) Attached Material Safety Data Sheet (MSDS).**) Gas, Solid, Liquid

5. Attached process flow diagram.

CapacityNoMaterial NameTrademarkAmountUnit6. Installed Production Capacity (per year)*

*) For non-industrial activities can be its activities, such as a hotel and hospital can be based on number of beds

CapacityNo.Product NameTrademarkAmountUnit7. Kapasitas Produksi senyatanya (Actual Product Capacity) (per year)

8. Activity/Business Timea. Number of Shift per day Shift b. Number of Production Hours:1) hours/ day2) day/month3) month/year4) day/year

9. Other Activities:

V. ENVIRONMENTAL INFORMATION

1. Certificate:ISO 9000 Year Assesor*) ISO 14000 Year Assesor*) Year Assesor*) *) Assesor is a consultant who has the right to audit and issue certificates

2. Does your company has environmental management policies?NoYes (Please Attach)

3. Does your company has Environmental Study Document?NoYes- Approval Number (Please Attach): - Document Type:- Implementation Consultan - Address

Phone: - Implementation Commission

4. Does your company every conduct Environmental Audit?NoYesEnvironmental Management, year Auditor Compliance Audit, year Auditor Risk Assesment), year Auditor , year Auditor

VI. WASTEWATER INFORMATION

1. Environmental Medium for WasteWater Disposal:River Name Lake Name Sea Name Others,

2. Does wastewater effluent stream continuous and regular? NoYes

3. Is there any wastewater treatment plant?YesRudimental In constructionFully constructed

4. If there was water treatment plant or it is being build, specify its processing capacity: m3/ day, does the system include the following?Grit Removal Coagulation Screening Sedimentation Grinding Active MudNeutralization Oxidation pool (lagoons) Equalization AnaerobicTrickling Filter AerobiCRotary Biological Contactor

Attach the lay out and the process flow diagram of wastewater treatment plants.5. Number of sewerage:

6.Sewerage Type: PipeOpen Channel

7. Were all the sewerage is equipped with measuring devices?NoYes

8. Indicate the type of sewerage measuring devices.Rectangular Weir Triangular Weir Venturi Meter Magnetic Flow Meter Current Meter Ultrasonic Meter Inductive meter

9. Average volume of wastewater m3/ day.10. Does your company ever analyze the waste water?NoYes (attach results of the final analysis of waste water quality, and specify the name of the laboratory used).

VII. SOLID WASTE INFORMATION

1. Is there any solid waste generated? No Yes, Weight ton/ day

2.Management Method: Chemistry-Physics-Biology Stabilization/ Solidificasion Insineration (Thermal Treatment) Landfill inside plantLandfill outside plantSend to PPLI-B3 (PT Prasadha Pamunah Limbah Industri)Send to VendorsSold to other parties

VIII.STATEMENT OF DIRECTOR / MANAGER FACTORY/ ACTIVITIES

I undersigned below hereby declare that all information written as stated above is true

Full Name

Signature & Company Stamp

Position

Ministry of Environment,

ttd

Based on the original, Deputy I of Environment Policy and Institutional

Signed

Hoetomo, MPA

Nabiel Makarim, MPA, MS