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Article 1
Every business and or activity is forbiden to dispose waste water containing radioactive to
water or water source
Article 2
Regent 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 month
c. Other documents related with the filing of the form attached in this decree
Article 5
The 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 disposed
d. 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.

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Article 6
Regent/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 7
Wastewater disposal permit to land controlled by its own legislation.
Article 8
The decree takes effect on the date specified.

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

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










139



Attachement:
Minister of Environment No. 111 2003, 27 June, 2003
Wastewater Disposal to Surface Water Permission Application
Nama 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)
140


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) :





141
III. PERMIT INFORMATION

State the number and agency issuing permit :
a. Izin Usaha (Business License)
Nomor : Number
Pemberi 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 (m
3
/ month):
a. PAM (Water Utility Company)
b. Air Tanah (Groundwater)
c. Sungai (River)
d. Laut (Sea)
e. Lainnya (Others)

3. Water Need (m
3
/ day) use for:
a. Produksi (Production)
b. Cooling water
c. Domestik (Domestic)
d. Lainnya (Others)
142
Source (%)
No Material Name Trademark Form Domestic Import







Capacity
No Material Name Trademark Amount Unit






Capacity
No. Product Name Trademark Amount Unit






4. Raw Material and Auxiliary *)








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

5. Attached process flow diagram.
6. 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

7. Kapasitas Produksi senyatanya (Actual Product Capacity) (per year)
143

8. Activity/Business Time
a. Number of Shift per day Shift
b. Number of Production Hours:
1) hours/ day
2) day/month
3) month/year
4) 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?
No
Yes (Please Attach)

3. Does your company has Environmental Study Document?
No
Yes
- Approval Number (Please Attach):
- Document Type:
- Implementation Consultan
- Address


Phone:
- Implementation Commission

4. Does your company every conduct Environmental Audit?
No
Yes
Environmental 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?
No
Yes

3. Is there any wastewater treatment plant?
Yes
Rudimental
In construction
Fully constructed
144





4. If there was water treatment plant or it is being build, specify its processing capacity: m
3
/ day, does the system include the
following?
Grit Removal Coagulation Screening
Sedimentation Grinding Active Mud
Neutralization Oxidation pool (lagoons)
Equalization Anaerobic
Trickling Filter AerobiC
Rotary Biological Contactor



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

6. Sewerage Type:
Pipe
Open Channel

7. Were all the sewerage is equipped with measuring devices?
No
Yes

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 m
3
/ day.
10. Does your company ever analyze the waste water?
No
Yes (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 plant
Landfill outside plant
Send to PPLI-B3 (PT Prasadha Pamunah Limbah Industri)
Send to Vendors
Sold 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