1964_AIR_POLLUTION_CONTROL_(SPECIFIED_PROCESSES)_REGULATIONS — Page 7

SECOND SCHEDULE

FORM 1

[regs. 4, 11, 12, 13 & 16.]

[reg. 4.]

AIR POLLUTION Control (SPECIFIED PROCESSES) REGULATIONS

APPLICATION FOR A LICENCE PURSUANT TO SECTION 14 OF THE AIR POLLUTION CONTROL ORDINANCE

1987 Ed.] Processes) Regulations Air Pollution Control (Specified

[CAP. 311

F 7

1.

I/We* the undersigned hereby apply under section 14 of the Air Pollution Control Ordinance for a licence for the conduct of the undermentioned specified process and I/we* hereby declare that the following particulars and the additional information, if any, provided are correct and the relevant plans and specifications are prepared by the qualified engineer(s)/authorized person(s) listed in paragraph 3 of the application.

I/We* enclose the application fee of $100.

This application, including plans and specifications, comprises pages.

Dated this day of 19

Signature of Applicant

Name

2.

Details of Owner(s)†

Name of the Owner(s)

(Surname First)

English

Identity Card/

Status

Correspondence Address

Telephone

Number

Chinese

Certificate of

Incorporation* Number

To: The Authority

* Delete if not applicable.

† Including the applicant.

i

[Subsidiary]