SURAT PENDAFTARAN ULANG O B Y E K R E 1 RIBUSI D A E R A H SPduORD ( S u r a t P e n d a f t a r a n U l a n g O b y e k R e t r i b u s i D a e r a h )

P e r i h a l : P e r m o h o n a n D a f t a r U l a n g I z i n T e m p a t U s a h a / I z i n G a n g g u a n

K e p a d a Y t h : K e p a l a D i n a s P e n a n a m a n M o d a l D a n P e l a y a n a n T e r p a d u S a t u P i n t u K a b u p a t e n B o y o l a l i D i -

B O Y O L A L I

Y a n g b e r t a n d a t a n g a n d i b a w a h i n i :

N a m a :

J a b a t a n / P e k e r j a a n :

A l a m a t : '.

N o m o r T e l e p o n :

M e n g a j u k a n p e r m o h o n a n D a f t a r U l a n g I z i n T e m p a t U s a h a / I z i n G a n g g u a n u n t u k u s a h a ; d e n g a n k e t e r a n g a n s e b a g a i b e r i k u t :

1 . A l a m a t / L o k a s i U s a h a : 2 . B e s a m y a I n v e s t a s i / M o d a l : 3 . J u m l a h D a y a K u d a / P K : 4 . L u a s R u a n g a n / F a s i l i t a s u n t u k u s a h a : M e t e r 5 . J u m l a h T e n a g a K e r j a : 6 . J e n i s d a n K a p a s i t a s P r o d u k s i . : 7 . J e n i s G a n g g u a n :

D e n g a n b a t a s - b a t a s s e b a g a i b e r i k u t :

a . S e b e l a h U t a r a :

b . S e b e l a h T i m u r :

c . S e b e l a h B a r a t :

d . S e b e l a h S e l a t a n :

S e b a g a i b a h a n p e r t i m b a n g a n , b e r s a m a i n i k a m i l a m p i r k a n :

a . I z i n T e m p a t U s a h a / I z i n G a n g g u a n A s l i y a n g s u d a h h a b i s m a s a b e r l a k u n y a ; b . F o t o C o p y K T P y a n g m a s i h b e r l a k u s e b a n y a k 2 ( d u a ) l e m b a r ; c . F o t o C o p y s e r t i f i k a t / s t a t u s t a n a h y a n g d i m o h o n k a n s e b a n y a k 1 ( s a t u ) l e m b a r ; d . F o t o C o p y P e n d i r i a n / a n g g a r a n d a s a r a p a b i l a b e r b e n t u k b a d a n h u k u m ; e . P a s P h o t o B e r w a m a u k u r a n 4 x 6 s e b a n y a k 2 ( d u a ) l e m b a r ; f . P e r s e t u j u a n L i n g k u n g a n / T e t a n g g a y a n g b e r d e k a t a n l a n g s u n g d e n g a n l o k a s i y a n g d i m o h o n k a n . g . F o t o C o p y N P W P h . F o t o C o p y 1 M B

D e m i k i a n u n t u k m e n j a d i k a n p e r i k s a .

P e m o h o n

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SURAT PERNYATAAN KESANGGUPAN P E N G E L O L A A N DAN PEMANTAUAN LINGKUNGAN HIDUP (SPPL)

K a m i y a n g b e r t a n d a t a n g a n d i b a w a h i n i : • N a m a : • J a b a t a n : • A l a m a t : • N o m o r T e l p . :

S e l a k u p e n a n g g u n g j a w a b a t a s p e n g e l o i a a n l i n g k u n g a n d a r i :

• N a m a p e r u s a h a a n / U s a h a : • A l a m a t p e r u s a h a a n / u s a h a : • N o m o r t e l p . P e r u s a h a a n : • J e n i s U s a h a / s i f a t u s a h a : • K a p a s i t a s P r o d u k s i : • L u a s B a n g u n a n :

d e n g a n d a m p a k l i n g k u n g a n y a n g t e r j a d i b e r u p a : 1. 2. 3. 4. 5 . d s t . m e r e n c a n a k a n u n t u k m e l a k u k a n p e n g e l o i a a n d a n p e m a n t a u a n d a m p a k

l i n g k u n g a n m e l a l u i : 1 . 2. 3. 4. 5 . d s t . P a d a p r i n s i p n y a b e r s e d i a u n t u k d e n g a n s u n g g u h - s u n g g u h u n t u k m e l a k s a n a k a n s e l u r u h p e n g e l o i a a n d a n p e m a n t a u a n d a m p a k l i n g k u n g a n s e b a g a i m a n a t e r s e b u t d i a t a s , d a n b e r s e d i a u n t u k d i a w a s i o l e h i n s t a n s i y a n g b e r w e n a n g .

T a n g g a l , B u l a n , T a h u n Y a n g m e n y a t a k a n , M a t e r a i d a n t a n d a t a n g a n

( N A M A )

N o m o r b u k t i p e n e r i m a a n o l e h i n s t a n s i L H

T a n g g a l :

P e n e r i m a :

D e n a h - U s a h a :

N a m a :

L o k a s i : D k . D k .

K e c a m a t a n

U

i • I

M e n g e t a h u i K e p a l a D e s a

PERSETUJUAN / PERNYATAAN TETANGGA YANG BERBATASAN

Y a n g b e r t a n d a t a n g a n d i b a w a h i n i k a m i :

N a m a : T a n d a T a n g a n

1 . A 1 .

T e t a n g g a s e b e l a h U t a r a - . v

2. T e t a n g g a s e b e l a h T i m u r

3. T e t a n g g a s e b e l a h S e l a t a n

4.

1 • - ^ I * ' - ^ '

T e t a n g g a s e b e l a h B a r a t

M e n y a t a k a n t i d a k k e b e r a t a n a t a s b e r d i r i n y a . . . y a n g d i m o h o n o l e h .

N a m a

A l a m a t

L o k a s i

D e m i k i a n p e r n y a t a a n i n i k a m i b u a t s e b e n a m y a d a n u n t u k d i g u n a k a n s e b a g a i m a n a m e s t i n y a . ;

M e n g e t a h u i K e p a l a D e s a / K e l u r a h a n

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