Department of Environment and Natural Resources

Environmental Management Bureau

Reference No:

(to be filled up by DENR only)

GENERAL INFORMATION SHEET

Name of the
M. MONTESCLAROS POULTRY BREEDER FARM
Establishment/Facility

Establishment/Facility Street # & Street Name: SITIO KINATE

Address Barangay: ALANIB City/Municipality: LANTAPAN
(NOT the company of head
office) Province : BUKIDNON
Name of
MR. MARIANITO R. MONTESCLAROS
Owner/Company
Street # & Street Name: _____________________________________
Address
(if address is not the same Barangay:______________ City/Municipality: ___________________
as previous address)
Province: __________________________________________

Phone Number NONE Fax Number NONE

e-mail address

Philippine Standard Industry Classification Code No. 1210

Type of Business/
Industry Philippine Standard Industry Descriptor: LIVESTOCK PRODUCTION
Classification
___

CEO/President. MR. MARIANITO R. MONTESCLAROS

Tel #: ___________________Fax #: ___

Responsible e-mail address: ___

Officer/s: Plant Manager: ___
Tel #: Fax #: ___
e-mail address: ___

Name. DR. MILDRED G. CAMILOTES

Pollution Control
Tel #: 09303015087 Fax #: ___
Officer
e-mail address: ___

 single proprietorship  partnership

Legal Classification  private domestic corporation  government corporation
 Multi-national  ___

We hereby certify that the above information are true and correct.

MR. MARIANITO R. MONTESCLAROS DR. MILDRED G. CAMILOTES

Name/Signature of CEO/President Name/Signature of PCO
Name of Plant:
Reference No:

Department of Environment and Natural Resources

Environmental Management Bureau

QUARTERLY SELF-MONITORING REPORT

THIRD QUARTER CY 2017

MODULE 1: GENERAL INFORMATION

Name of the Plant M. MONTESCLAROS POULTRY BREEDER FARM
Please provide the necessary revised, corrected or updated information not contained in your
General Information Sheet

(use additional sheet/s if necessary)

DENR Permits/Licenses/Clearances
Environmental
Permits Date of Issue Expiry Date
Laws
A/C No.
P.D. 984
PO No. 2015 -DP-D-1013-480 April 13,2015 April 12,2020
Feb. 6,2002
10(13)02 02-06 1984-
ECC 1 Amended on
12211
April 11,2011
PD 1586
ECC 2

ECC 3
DENR
Registry ID
None
CCO Registry None
RA 6969 Importer
Clearance No
None
Permit to
Transport
None
A/C No. None
RA 8749
PO No. None

Module 1: General Information page ____ of ____

Name of Plant:
Reference No:

Operation
Operating hours/day Operating days/week # of shift/day
Average 8 7
Maximum 8

Operation/Production/Capacity:
Average Daily Total Output this
GROWING STAGE GROWING STAGE
Production Output Quarter
Total Water Total Electric
Consumption this 1,300 Consumption this 253,979.1
Quarter (cubic meters) Quarter (KwH)
Please use additional sheet/s if necessary

MODULE 2: RA 6969

A. CCO Report (please accomplish this se4ction for each chemical/substance)

Common Name/IUPAC/CAS Index Name. ___

CAS No.: ___
Trade Name: ___

For importers only:

Import
Quantity Date of Quantity Port of Country of Country of
Clearance
Requested Arrival Received* Entry Origin Manufacture
No.

Total Quantity Total Quantity

Requested (annual) Received (annual)
* attach copy/s of Bill of Lading

For distributors (importers/non-importers)

Name of Client License No. Quantity Date of Distribution

Total Quantity Distributed

For non-importer users:

Name of Distributor Quantity Date of Purchase

Total Quantity Purchased from Distributor

Module 2A: RA 6969 (CCO Report) page ____ of ____

Name of Plant:
Reference No:

For producers
Average Daily Total Output this
Production Output Quarter
Quantity of Stock Quantity of Stock
Inventory (Start of Inventory (End of
Quarter) Quarter)
Name of Buyer Quantity Date of Purchase

Total Quantity Sold

Used in Production (please fill up only if chemical/substance is not main product)

Average Daily Total Output this
Production Output Quarter
Average Quantity Used Total Quantity Used
per month this Quarter
Describe any changes in Production/Process/Operations:

Stock Inventory/Waste Chemical Generated:

Average Quantity of Total Quantity of Waste
Waste Chemical Chemical Generated
Generated per month this Quarter
Quantity of Stock Quantity of Stock
Inventory (Start of Inventory (End of
Quarter) Quarter)

Other Information:
Manner of handling  storage on-site  Treatment on-site
hazardous wastes  storage off-site  Treatment off-site

Changes in Safety  Yes (please attach copy of revised plan)

Management System  No

Chemical Substitute  Yes (please attach copy if not submitted/included in previous report/s or had been revised)
Plan  No

Module 2A: RA 6969 (CCO Report) page ____ of ____

Name of Plant:
Reference No:

B. Hazardous Wastes Treat/Recyler

HW Stored and/or Untreated as of End of Quarter:

Type of
Transport Storage Time Table
HW Wastes Date of
Permit/Date Valid until Quantity Container/ for
Number Generator Transport
of Issue # of Treatment
containers

HW Treated and/or Recycled as of End of Quarter:

Type of Type &
Transport Treatment Quantity of
Type of HW Wastes Date of
Permit/Date Quantity or Recycled
Wastes Number Generator Transport
of Issue Recycling or Treated
Process Product

Residual Wastes Generated from the Treatment and/or Recycling Operation:

Type of
Process by
Storage
Type of which the Disposal Time Table
HW Number Quantity Container/
Wastes Wastes is Option for Disposal
# of
Generated
containers

C. Hazardous Wastes Generator

HW Generation:
Remaining HW from
HW HW Generated
HW No. HW Class HW Nature Previous Report
Cataloguing
Quantity Unit Quantity Unit

Module 2B: RA 6969 (Hazardous Wastes Treater/Recycler) page ____ of ____

Name of Plant:
Reference No:

Waste Storage, Treatment and Disposal:(Please fill-up one table per HW)
HW No,: ___
HW Details Qty of HW Treated: Unit: ___
TSD Location: ___

Name: ___
Storage
Method: ___

ID: Name: ___

Transporter
Date: ___

ID: Name: ___

Treater
Method: Date: ___

ID: Name: ___

Disposal
Date: Date: ___

HW No,: ___
HW Details Qty of HW Treated: Unit: ___
TSD Location: ___

Name: ___
Storage
Method: ___

ID: Name: ___

Transporter
Date: ___

ID: Name: ___

Treater
Method: Date: ___

ID: Name: ___

Disposal
Date: Date: ___

On-Site Self Inspection of Storage Area:

Premises/Area Findings & Corrective Action
Date Conducted
Inspected Observations Taken (if any)
N/A

Module 2C: RA 6969 (Hazardous Wastes Generator) page ____ of ____

Name of Plant:
Reference No:

MODULE 3: P.D. 984 (Water Pollution)

Water Pollution Data

Domestic wastewater Process wastewater
5.0
(cubic meters/day) (cubic meters/day)
Cooling water Others: ___________
(cubic meters/day) (cubic meters/day)
Wash water, Wash water, floor
5.0
equipment (m3/day) (cubic meters/day)

Record of Cost of Treatment

Month 1 Month 2 Month 3
New/Additional
Investments in WTP
(Description)
Cost of New/Add
Investments
Person employed, (# of
employees)
Person employed,
(cost)
Cost of Chemicals
used by WTP
Utility Costs of WTP
(electricity & water)
Administrative and
Overhead Costs
Cost of operating in-
house laboratory

WTP Discharge Location

Outlet
Location of the Outlet Name of Receiving Water Body
Number
1
2
3
4
5

Module 5: P.D. 1586 (EIS System) page ____ of ____

Name of Plant:
Reference No:

Detailed Report of Wastewater Characteristics for Conventional Pollutants

Outlet No.

Effluent Oil & ________

BOD TSS Temp rise (name)
DATE Flow Rate Color pH Grease
(mg/L) (mg/L) (ºC)
(m3/day) (mg/L)
(unit)

Please fill-up/accomplish separate form/s for other outlet/s.

Detailed Report of Wastewater Characteristics for Other Pollutants

Outlet No.

Effluent ________ ________ ________ ________ ________ ________ ________

(name) (name) (name) (name) (name) (name) (name)
DATE Flow Rate
(m3/day)
(unit) (unit) (unit) (unit) (unit) (unit) (unit)

Please fill-up/accomplish separate form/s for other outlet/s.

Please use additional sheet/s if necessary

MODULE 4: R.A. 8749 (Air Pollution)

Summary of APSE/APCF
Process Equipment Location # of hrs of operations
1.NONE
2.
Fuel Burning Equipment Location # of hrs of operations
1.NONE
2.
6.
Pollution Control Facility Location # of hrs of operations
1.NONE
2.

Module 5: P.D. 1586 (EIS System) page ____ of ____

Name of Plant:
Reference No:

Cost of Treatment
Month 1 Month 2 Month 3
Improvement or
modification, if any.
(Description)
Cost of improvement of
modification
Cost of Person
employed, (salary)
Total Consumption of
Water (cubic meters)
Total Cost of chemicals
used (e.g., activated
carbon, KMnO4)
Total Consumption of
Electricity (KwH)
Administrative and
Overhead Costs
Cost of operating in-
house laboratory, if any

Detailed Report of Air Emission Characteristics

Description/Location
of PCF
________ ________ ________ ________
Flow Rate CO NOx Particulates (name) (name) (name) (name)
DATE
(Ncm/day) (mg/Ncm) (mg/Ncm) (mg/Ncm)
(mg/Ncm) (mg/Ncm) (mg/Ncm) (mg/Ncm)

Please fill-up/accomplish separate form/s for other PCF/s.

Please use additional sheet/s if necessary.

MODULE 5: P.D. 1586

Ambient Air Quality Monitoring (if required as part of ECC conditions)

Description/Location
of Monitoring Station
________ ________ ________ ________
Noise CO NOx Particulates (name) (name) (name) (name)
DATE
Level (dB) (mg/Ncm) (mg/Ncm) (mg/Ncm)
(mg/Ncm) (mg/Ncm) (mg/Ncm) (mg/Ncm)

(Please accomplish one table per monitoring station.)

Module 5: P.D. 1586 (EIS System) page ____ of ____

Name of Plant:
Reference No:

Ambient Water Quality Monitoring (if required as part of ECC conditions)

Description/Location
of Sampling Station
________ ________ ________ ________ ________ ________ ________ ________
(name) (name) (name) (name) (name) (name) (name) (name)
DATE
(unit) (unit) (unit) (unit) (unit) (unit) (unit) (unit)

(Please accomplish one table per sampling station.)

Other ECC Conditions

Status of Compliance
ECC Condition/s Actions Taken
Yes No

1.
2.
3.
4.
5.
Please use additional sheet/s if necessary.

Environmental Management Plan/Program

Status of
Enhancement/Mitigation Measures Implementation Actions Taken
Yes No

1.Maintenance of planted trees /

2.Regular application of disinfectant /
3.Proper disposal of solid wastes /
4.Regular maintenance of drainage system /
5.
6.
7.
8.
9.
10.
11.
Please use additional sheet/s if necessary.

Module 5: P.D. 1586 (EIS System) page ____ of ____

 Procedural and Reference Manual for DAO 2003-27

MODULE 6: OTHERS

Accidents & Emergency Records

Findings and
Date Area/Location Actions Taken Remarks
Observation

Personnel/Staff Training
# of Personnel
Date Conducted Course/Training Description
Trained

August 25-26,2011 Training course for Pollution 1

Control Officer

March 20-21,2013 Basic training course for pollution 1

control officers

March 12 to 14,2014 Basic training course for pollution 1

control officers

Nov. 23 to 27,2015 Basic training course of pollution 1

control officers

I hereby certify that the above information are true and correct.

Done this _________________________, in ________________________.

MR. MARIANITO R. MONTESCLAROS DR. MILDRED G. CAMILOTES

Name/Signature of CEO Name/Signature of PCO

Preparation and Submission of SMR 11