<p> ANNEXURE TO FORM – 1</p><p>Report of Analysis of Treated Effluent showing performance of the Treatment Plant for the Month of ...... </p><p>SAMPLE COLLECTED ON : SAMPLE TESTED ON : BY THE LABORATORIES :</p><p>SL Polluting parameters as mentioned in the Maximum permissible limits Concentration of range of Dates on which, there was On which under NO. condition imposed under consent granted or ranges allowed as per parameters as per report breakdown or failure of performance was noticed under section 25/26 of the consent conditions the plant water (prevention and Control of Pollution) Act, 1974. </p><p>1 2 3 4 5 6</p><p>Encl : Original Analysis Report of Laboratory. Signature : Date : Name : Address : Form-1 See Rule- 4 Returns Regarding Water Consumed during the Month of………………………</p><p>Name and address Purpose for which Water Reading at the begining of Reading at the end Quantity of water If the meter was out of Quantity of water Remarks (*) of the consumer consumed the first day of the calendar of the last day of consumed in order, the monthly qualifying for rebate month under report calendar month kilo-litres average consumption according to the under report of water for the previous assessee 3 months of the working period</p><p>1 2 3 4 5 6 7 8</p><p>Industrial cooling, spraying in mine pits or boiler feed i from Municipal Water supply mains. ii from well tubewell. iii from canal. iv from river. v from any other source.</p><p>Domestic purpose i from Municipal Water supply mains. ii from well Tubewell. iii from cannal. iv from any other source.</p><p>Processing whereby water gets polluted and i from Municipal Water supply mains. the pollutants are easily bio-degradable ii from well tubewell. iii from canal. iv from river. v from any other source.</p><p>Processing whereby water gets polluted and i from Municipal Water supply mains. the pollutants are not easily bio-degradable and are toxic ii from well tubewell. iii from canal. iv from river. v from any other source.</p><p>(*) for claiming rebate under Col.7 of the assessee shall indicate in this column the analytical and other reports annexed to this returns in support of this claim.</p><p>Signature of the Consumer : </p><p>Name : </p><p>Address :</p>