8/20/2019 Pkm-borang Jas as Pat Penang[1] http://slidepdf.com/reader/full/pkm-borang-jas-as-pat-penang1 1/14 1 Borang AS PAT 1-12 AS PA T 1-12 Fo rm A. JENIS PERMOHONAN TYPE OF APPLICATION 1. Bukan Aktiviti Yang Ditetapkan (Bukan EIA) Non Prescribed Activity (Non EIA) Jenis pembangunan: Type of development: ________________________________________________ ________________________________________________ 2. Aktiviti Yang Ditetapkan (EIA) di bawah Perintah Kualiti Alam Sekeliling (Aktiviti Yang Ditetapkan) (Penilaian Kesan Kepada Alam Sekeliling), 1987, Akta Kualiti Alam Sekeliling, 1974. Prescribed Activity (EIA) listed under the Environmental Quality Order (Prescribed Activity)(Environmental Impact Assessment), 1987, Environmental Quality Act, 1974 a. Jenis Aktiviti EIA (nyatakan Aktiviti Yang Ditetapkan) Types of EIA Activity (state the Prescribed Activity) _____________________________________________ _____________________________________________ _____________________________________________ UNTUK KEGUNAAN JABATAN AL SEKITAR (FOR DOE USE) Maklumat Lengkap Complete Information Maklumat Tid Lengkap Incomplete Information Ulasan: Comment: Ulasan: Comment:BORANG AS PAT 1-12 PENILAIAN AWAL TAPAK BAGI PROJEK PEMBANGUNAN AS PAT 1-12 FORM PRELIMINARY SITE ASSESSMENT FOR DEVELOPMENT PROJECT Nota: Note: a. Sila tandakan “ √” di dalam kotak, yang mana berkenaan. Tick “ √” in the box, where appropriate . b. Bahagian A hingga I untuk dilengkapkan oleh pemohon, yang mana berkenaan. Parts A to I are to be completed by applicant, where appropriate. c. Sila kemukakan borang permohonan PAT ini kepada Jabatan Alam Sekitar Negeri yan berkenaan setelah Bahagian I dilengkapkan. Please submit this PAT application form to the relevant Department of Environment Sta Office upon the completion of Part I. d. Bahagian J untuk kegunaan Jabatan Alam Sekitar. Part J is for DOE use. e. Salinan dokumen yang disertakan hendaklah disahkan benar. Attached document must be certified true copy. Lampiran 2
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1. Bukan Aktivit i Yang Ditetapkan (Bukan EIA)Non Prescribed Activity (Non EIA)
Jenis pembangunan:
Type of development:
________________________________________________
________________________________________________
2. Aktivi ti Yang Ditetapkan (EIA) di bawah PerintahKualiti Alam Sekeliling (Aktiviti Yang Ditetapkan)(Penilaian Kesan Kepada Alam Sekelil ing), 1987,
Akta Kual it i Alam Sekelil ing, 1974.Prescribed Activi ty (EIA) listed under the EnvironmentalQuality Order (Prescribed Activity)(EnvironmentalImpact Assessment), 1987, Environmental Quality Act,1974a. Jenis Aktivi ti EIA (nyatakan Aktiviti Yang Ditetapkan)
Types of EIA Activity (state the Prescribed Activity) _____________________________________________
_____________________________________________
_____________________________________________
UNTUK KEGUNAAN JABATAN ALSEKITAR (FOR DOE USE)
MaklumatLengkapComplete
Information
Maklumat TidLengkap
Incomplete
Information
Ulasan:Comment:
Ulasan:
Comment:
BORANG AS PAT 1-12
PENILAIAN AWAL TAPAK BAGI PROJEK PEMBANGUNAN
AS PAT 1-12 FORM
PRELIMINARY SITE ASSESSMENT FOR DEVELOPMENT PROJECT
Nota:Note:a. Sila tandakan “√” di dalam kotak, yang mana berkenaan.
Tick “√” in the box, where appropriate .
b. Bahagian A hingga I untuk di lengkapkan oleh pemohon, yang mana berkenaan.
Parts A to I are to be completed by applicant, where appropriate.
c. Sila kemukakan borang permohonan PAT ini kepada Jabatan Alam Sekitar Negeri yan
berkenaan setelah Bahagian I dilengkapkan.
Please submit this PAT application form to the relevant Department of Environment Sta
Office upon the completion of Part I.
d. Bahagian J untuk kegunaan Jabatan Alam Sekitar.
Part J is for DOE use.
e. Salinan dokumen yang disertakan hendaklah disahkan benar.
b. Power of Attorney (PA) (Sertakan salinan dokumen
PA yang berkenaan) Power of Attorney (PA) (Kindly attach a copy of
the PA document)
8. Keluasan Keseluruhan Tapak Cadangan Projek: Total Area for the Proposed Project Site: ______________________________________________
9. Guna Tanah berdasarkan Zon Perancangan:Land Use in accordance to the Planning Zone:
a. Zon Perancangan: __________________________Planning Zone:
b. Rancangan Struktur/Tempatan/ RancanganKawasan Khas (RKK):Structure Plan/Local/Special Planning Area: _________________________________________
c. No. Blok Perancangan: ______________________Planning Block No:(Rujukan daripada Pelan Perancangan oleh JabatanPerancang Bandar dan Desa Negeri atau PihakBerkuasa Tempatan yang berkenaan)
(Reference made to the Planning document by theDepartment of Town and Country Planning or therelevant Local Municipal Council)
d. Guna tanah tapak cadangan projek:(i) Perumahan, Housing. (ii) Pertanian, Agriculture. (iii) Perindustrian, Industrial.
(Rujuk Garispanduan Siting and Zoning ofIndustries and Residential Area, terbitan Jabatan
Alam Sekitar)(refer to the Guidelines for the Siting and Zoning ofIndustries and Residential Area by the Departmentof Environment)
(iv) Lain-lain Gunatanah (nyatakan):Other Land Use (state):
e. Guna tanah sekeliling berdasarkan Zon Perancangan.(dalam lingkungan sekurang-kurangnya 500 meter jejari darisempadan cadangan projek)
Surrounding land use in accordance to the PlanningZone: (at least 500 meter radius from the boundary of theproposed project)
(i) Perumahan, Housing. (ii) Pertanian, Agriculture. (iii) Perindustrian, Industrial.
(Rujuk Garispanduan Siting and Zoning of Industriesand Residential Area, terbitan Jabatan Alam Sekitar)(refer to the Guidelines for the Siting and Zoning ofIndustries and Residential Area by the Departmentof Environment)
(iv) Lain-lain Gunatanah (nyatakan):Other Land Use (state):
______________________________________
______________________________________
f. Berdasarkan Zon Perancangan dan keadaan sekeliling,nyatakan jarak terdekat di antara sempadan tapakcadangan projek dengan:Based on the Planning Zone and surroundingenvironment, please state the nearest distance betweenthe project boundary to the:
(i) penempatan penduduk: jarak ______________residential: distance
(ii) sekolah: jarak __________________________school: distance
(iii) klinik kesihatan: hospital, jarak _____________Health clinic, hospital: distance
(iv) paya bakau: jarak _______________________mangrove: distance
(v) kawasan RAMSAR______________________: jarak ______________RAMSAR site: distance
(vi) kawasan wetland _______________________: jarak _______________Wetland area: distance
(vii) Taman Laut ____________________________: jarak ______________Marine Park: distance
(ix) Taman Negara __________________________: jarak ______________
National Park: distance(x) kawasan industri ________________________:
jarak ______________industrial area : distance
(xi) Lain-lain (nyatakan): ______________________: jarak _______________Others (state): distance
E. MAKLUMAT CADANGAN PROJEKINFORMATION ON PROPOSED PROJECT
10. Cadangan projek adalah selaras dengan: Proposed project is in line with: a. Rancangan Fizikal Negara terkini (RFN) terbitan
Jabatan Perancang Bandar dan Desa.Latest version of the National Physical Plan byFederal Department of Town and Country Planning.
b. Rancangan Struktur Negeri (RSN) _____________ State Structure Plan (RSN)
c. Rancangan Tempatan (RT) ___________________ Local Plan (RT)
d. Zon Perancangan ___________________________
e. Rancangan Kawasan Khas (RKK) ______________Special Planning Area (RKK)
f. *Perjanjian Kerajaan Malaysia dengan syarikat Kualiti Alam Sdn Bhd mengenai pengolahan dan pelupusan buangan terjadual.
*Agreement between the Government of Malaysia andKualiti Alam Sdn Bhd for the treatment and disposal ofscheduled wastes.
g. Garispanduan Perancangan Pembangunan diKawasan Bukit dan Tanah Tinggi, terbitanKementerian Perumahan Kerajaan Tempatan (KPKT)
Guidelines on the Development Planning at Hilly Areaand Highland, by the Ministry of Housing and LocalGovernment (KPKT).
h. *Perjanjian Kerajaan Malaysia dengan syarikatpelupusan buangan klinikal (bagi hospital Kerajaan).* Agreement between the Government of Malaysia andConcessionaires for the disposal of clinical wastes(Government hospitals)
* : Semakan akan dijalankan oleh Jabatan Alam Sekitar.*: Verification by the Department of Environment.
14. Huraian Proses PengeluaranDescription of Production ProcessesTerangkan secara terperinci proses pengeluaran danlampirkan carta alir proses yang berkaitan.Describe in detail all production processes and attach
17. Maklumat Mengenai PencemaranInformation on Pollution
a. Dari rajah aliran bagi semua proses pengeluaran,tunjukkan tempat pelepasan pencemaran dan jenisnya. From the flow diagrams attached, show the points of
emission/ discharge and types of pollutants emitted. Tempat Pelepasan Jenis Pencemar Kuanti ti
Points of Emission/ Types of Pollutants QuantityDischarge
18. Saya yang bertandatangan di bawah ini mengaku bahawasegala maklumat yang diberi dalam borang ini adalah benardan betul sepanjang pengetahuan saya.I, the undersigned, certify that the information given in thisapplication form is to the best of my knowledge is true andcorrect.
Nama Pemohon:___________________________________Name of Applicant:
H. ULASAN OLEH AGENSI BERKAITANCOMMENTS FROM RELEVANT AGENCIES
19. Ulasan oleh Jabatan Perancang Bandar dan Desa IbuPejabat (sekiranya berkaitan dokumen Rancangan FizikalNegara)
Comments from the Federal Department of Town andCountry Planning (if related to National Physical Plan)
− Sekiranya cadangan projek adalah penambakan laut, ataudicadangkan di kawasan sensitif alam sekitar, di kawasanCentral Forest Spine (CFS) atau lain-lain pembangunan yangberkaitan.
− For proposed land reclamation project or project proposed atenvironmental sensitive area, at Central Forest Spine (CFS)
or other related developments.
a. Lampirkan surat/ulasan dan pengesahan yangberkaitan dari Jabatan Perancang Bandar danDesa (JPBD) Ibu Pejabat.
Attach relevant letter/comment and endorsementfrom the Federal Department of Town andCountry Planning.
20. Ulasan oleh Jabatan Perancang Bandar dan Desa Negeri ____________________ (sekiranya berkaitan dokumenRancangan Struktur Negeri atau pelan lain yang dirujuk)
Comments from the Department of Town and CountryPlanning, State of _________________ (if related to the StateStructure Plan or other plans)
a. Lampirkan surat/ulasan dan pengesahan yangberkaitan dari Jabatan Perancang Bandar danDesa Negeri.
Attach relevant letter/comment and endorsementfrom the Department of Town and CountryPlanning, State Office.
21. Ulasan dari Pihak Berkuasa Tempatan (nyatakan Pihak
Berkuasa Tempatan) _____________________________
_____________________________________________
(sekiranya berkaitan dokumen Rancangan Tempatan
atau Rancangan Kawasan Khas)
Comments from the Local Municipal Council (state the
Local Municipal Council) ___________________________ _____________________________________________(if related to the Local Plan or Special Area Plan)
a. Lampirkan surat/ulasan dan pengesahan yangberkaitan dari Pihak Berkuasa Tempatan.
Attach relevant letter/comment and endorsement
from the Local Municipal Council.
I. SENARAI SEMAK PERMOHONAN APPLICATION CHECKLIST
No.No.
PerkaraSubject
AdaYes
TiadaNo
LengkapComplete
TidakLengkap
Incomplete
1 Surat rasmi dari pemohon bagi menerangkan
maksud permohonan PAT.Formal letter from applicant, explaining thepurpose of the PAT application.
2 Borang AS PAT diisi dengan lengkap.Completed AS PAT form.
3 Ulasan dari agensi berkaitan (rujuk Bahagian H)Comments from relevant agencies (refer to PartH)