Republic of the Philippines

DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCES

ENVIRONMENTAL MANAGEMENT BUREAU Office of the Regional Director

Region IX, Western Mindanao 2/F Pastoriza Bldg., Datoc St., Gatas District, Pagadian City (062) 215-4137

Application for Discharge Permit New Renewal Application No.

INSTRUCTION: Fill in all appropriate white spaces. Mark all appropriate boxes with an X. NOTE: Failure to complete this form may be sufficient ground for disapproval of the permit application. GENERAL INFORMATION
Name of Establishment/Plant Est. Code Year Est.

Expiry Date

TIN

Plant Address: No. & Street Name City or Municipality Type of Industry Name of PCO Tel. No. & Cel. No.

Barangay Province

Accreditation Date Fax No.

Legal Classification Proprietorship Private Corporation Multinational Others, specify

Ownership Terms (%)

Private

Foreign

Government

EMPLOYMENT AND OPERATION INFORMATION

Total Employment (number of workers) in the factory: Production Time: Number of Hours/day Production Number of days/month Non-Production Number of months/year

SOURCES OF WATER SUPPLY AND WASTEWATER GENERATION

Sources of Water Supply Monthly Ave. Vol. (m3) Daily Ave. Vol. (m3) Generating Process Estimated Flow (m3)

MWSS (Please water bills)

attach

Process Water

Local Water District (Please attach water bills) Deep wells

Washing/Cleaning of Process Water

Cooling

Surface waterbodies, river, creek, etc. Others

Domestic

Recycled/Reuse Others (drinking water, gardening, evaporation, leaks, product component, etc.)

Total Water Consumption

Total Volume Wastewater

of

Discharge

Dwelling Units Information (hotels, condominium, restaurants, malls, etc)

Total Floor Area Total Area for Dwelling Unit (m2) No. of Bedrooms No. of Restaurants/Dining Unit No. of Guest/Year

PRODUCTION INFORMATION
Product 1 Product Name Product 2 Product 3

Actual Production

Actual Production in the Previous Year

Type of Process

Batch Continuous

Batch Continuous

Batch Continuous

Note: **Please use generic product name, not in brand names, in metric tons of product, carbonated drinks and beer (m3) Except for the following substances: hog raising (heads), slaughtering/preserving

Water Pollution Information

Outlet Number Location & Distribution of Outlet Name of the Receiving body if not discharging in the lake Estimated Ave. BOD/TSS conc. (mg/L) Estimated Ave. Rate of Discharge (m3/day) Estimated BOD/TSS (kg/day) Average Load

1 2 3 Total

Name of Laboratory Performing Analysis: Address of Laboratory: Date of Sampling: Date of Analysis: Method of Sampling: Vicinity Map (The map should show relative location of the establishment with respect to existing structures, landmarks, rivers, lakes and other water bodies, etc.. Use scale to fit into the frame below.)

Fixed Fee Official Receipt Number:__________________________________ Date of Issue:___________________ I hereby certify that the above information are true and correct to the best of my knowledge. Done this ___ day of ____________ of 20____. ____ ______________________________________ Name and Signature of Pollution Control Officer ______ _ ________________________ Chief Executive Officer

SUBSCRIBED AND SWORN to before a Notary Public. This ______________ day of ________________. Affiant exhibiting to me his/her Community Tax Receipt No. _________________________________ issued at ____________________ on ________________________.

_________________________________ Notary Public Doc. No.________ Page No.________ Book No.________ Series of ________

REQUIREMENTS FOR APPLICATION FOR A WASTEWATER DISCHARGE PERMIT FOR NEW APPLICATION: Name of Establishment: Address: A) Engineers Report 1. Vicinity Map 2. Nature of Project or Business 3. Production Capacity Quantity or Volume and Generic Name/s of Product/s 4. Nature and character of the applicants wastewater and its physical and chemical composition

5. Total daily volume of discharge of raw wastewater 6. Treatment process and estimated treatment efficiency 7. Total daily volume of water consumption and discharge of final treated wastewater or effluent 8. The name of receiving body of water and its official water classification and in case of land discharge, the nearest receiving body of water and its official water classification 9. Information on flow measurement equipment and procedure 10. Pollution prevention/Environmental System plan or program 11. DENR ID Number as hazardous waste generator (if applicable) 12. Statement of the cost incurred in the installation and maintenance of wastewater treatment facility, if any 13. Quality and quantity of abstracted water 14. Copy of ECC or CNC (if applicable)