Department of Environment and Natural Resources

Environmental Management Bureau

Reference No:
(to be filled up by DENR only)

GENERAL INFORMATION SHEET

Name of the
FUEL 1 GASOLINE STATION
Establishment/Facility

Establishment/Facility Street # & Street Name: AMBANGAN ROAD ___

Address Barangay: LIBERTAD City/Municipality: BUTUAN CITY ___
(NOT the company of head
office) Province: AGUSAN DEL NORTE
Name of
RETLY MANANSALA
Owner/Company
Street # & Street Name: HAPPY HOMES SUBDIVISION ___
Address
(if address is not the same as Barangay: LIBERTAD City/Municipality: BUTUAN CITY ___
previous address)
Province: AGUSAN DEL NORTE

Phone Number 861-6641 Fax Number

e-mail address [email protected]

Philippine Standard Industry Classification Code No. ___

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

CEO/President. RETLY G. MANANSALA ___

Tel #: 861-441 Fax #: ___
e-mail address: [email protected] ___
Responsible Officer/s:
Plant Manager: MERY ANN S. CARADO ___
Tel #: 09505304480 Fax #: ___
e-mail address: [email protected] ___

Name. SARAH MAE S. DUHAC (ON PROCESS ) ___

Pollution Control
Tel #: 09385662299 Fax #: ___
Officer
e-mail address: [email protected] ___

 single proprietorship  partnership

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

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

RETLY G. MANANSALA _SARAH MAE DUHAC__

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

Department of Environment and Natural Resources

Environmental Management Bureau

1ST QUARTERLY SELF-MONITORING REPORT

MODULE 1: GENERAL INFORMATION

Name of the Plant FUEL 1 GASOLINE STATION
Please provide the necessary revised, corrected or updated information not contained in your General
Information Sheet

The proposed gasoline filling and service station project covers an area of 385 square
meters declared under Tax Declaration No. 96GR-06-003-2366-R in the name of Mr.
Bonifacio Yu wherein a Conditional Deed of Assignment and Transfer of Rights and
Interests was executed between the proponent and Mr. Yu, assigning and conveying, in a
manner absolute and irrevocable the said property in favor of the proponent.

The proposed project has a maximum fuel storage capacity of 40, 000 liters. The project
facilities and structure include: one (1) service bay, two (2) pumping/refilling stations, two
dispensing pump for fueling position, three (3) fuel storage tanks, one (1) wash bay, two (2)
convenience store, one by stand –by power utility, parking area, office bldg. with public
toilets. It will also provide services such as manual washing, shampoo/vacuum, change oil,
greasing, change coolant, tune-up, and wheel alignment.

(use additional sheet/s if necessary)

DENR Permits/Licenses/Clearances

Module 1: General Information page ____ of ____

Name of Plant:
Reference No:

Environmental
Permits Date of Issue Expiry Date
Laws
A/C No.
P.D. 984
PO No.

ECC 1 ECC- R13-107-0103 2011-07-28

PD 1586 ECC 2

ECC 3
DENR
Registry ID
N/A 2000-01-01 2000-01-01
CCO Registry N/A 2000-01-01 2000-01-01
RA 6969 Importer
Clearance No
N/A 2000-01-01 2000-01-01
Permit to
Transport
N/A 2000-01-01 2000-01-01
A/C No.
RA 8749
PO No.

Operation
Operating hours/day Operating days/week # of shift/day
Average 19 90 3
Maximum 19 90 3

Operation/Production/Capacity:
Average Daily
1100 Total Output this Quarter 92798
Production Output
Total Water Consumption Total Electric
this Quarter (cubic 33 Consumption this Quarter 9.6
meters) (KwH)
Please use additional sheet/s if necessary

Module 1: General Information page ____ of ____

Name of Plant:
Reference No:

MODULE 2: RA 6969

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

Common Name/IUPAC/CAS Index Name. N/A ___

CAS No.: N/A ___
Trade Name: N/A ___

For importers only:

Import
Quantity Date of Quantity Country of Country of
Clearance Port of Entry
Requested Arrival Received* Origin Manufacture
No.
N/A
N/A
N/A
N/A
N/A
N/A
Total Quantity Requested Total Quantity Received
(annual) (annual)
* attach copy/s of Bill of Lading

For distributors (importers/non-importers)

Name of Client License No. Quantity Date of Distribution
N/A
N/A
N/A
N/A
N/A
N/A
Total Quantity Distributed

For non-importer users:

Name of Distributor Quantity Date of Purchase
N/A
N/A
N/A
N/A
N/A
N/A
Total Quantity Purchased from Distributor

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

Name of Plant:
Reference No:

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

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

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

N/A

Stock Inventory/Waste Chemical Generated:

Average Quantity of Total Quantity of Waste
Waste Chemical N/A Chemical Generated this N/A
Generated per month Quarter
Quantity of Stock Quantity of Stock
Inventory (Start of N/A Inventory (End of N/A
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 2B: RA 6969 (Hazardous Wastes Generator) page ____ of ____

Name of Plant:
Reference No:

B. Hazardous Wastes Generator

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

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

Name: N/A ___

Storage
Method: ___

ID: N/A Name: ___

Transporter
Date: ___

ID: N/A Name: ___

Treater
Method: Date: ___

ID: N/A Name: ___

Disposal
Date: Date: ___

HW No,: N/A ___

HW Details Qty of HW Treated: Unit: ___
TSD Location: ___

Name: N/A ___

Storage
Method: ___

ID: N/A Name: ___

Transporter
Date: ___

ID: N/A Name: ___

Treater
Method: Date: ___

ID: N/A Name: ___

Disposal
Date: Date: ___

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

Name of Plant:
Reference No:

On-Site Self Inspection of Storage Area:

Corrective Action Taken
Date Conducted Premises/Area Inspected Findings & Observations
(if any)
Segregate as to its
June 15, 2019 Storage area Found some garbage
classification

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

Name of Plant:
Reference No:

C. Hazardous Wastes Treater/Recycler

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

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

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

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

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

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

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

Name of Plant:
Reference No:

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

Water Pollution Data

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

Record of Cost of Treatment (Separate entries for separate facilities)

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

New/Additional
N/A
Investments in WTP
(Description)

Cost of New/Add N/A

Investments

WTP Discharge Location

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

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

N/A

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

Module 3: P.D. 984 (Water Pollution) page ____ of ____

Name of Plant:
Reference No:

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)
N/A

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

Please use additional sheet/s if necessary.

Module 3: P.D. 984 (Water Pollution) page ____ of ____

Name of Plant:
Reference No:

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

Summary of APSE/APCF
Process Equipment Location # of hrs of operations
1. N/A
2.
3.
4.
Fuel Burning Quantity # of hrs of
Location Fuel Used
Equipment Consumed operations
1. GENSET POWER HOUSE DIESEL 15 LITERS 6 HOURS
2.
3.
4.
5.
6.
Pollution Control Facility Location # of hrs of operations
1. N/A
2.
3.
4.

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

Improvement or
N/A
modification, if any.
(Description)

Cost of improvement of N/A

modification

Module 4: RA 8749 (Air Pollution) page ____ of ____

Name of Plant:
Reference No:

Detailed Report of Air Emission Characteristics

Description/Location
N/A
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)
N/A

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

Please use additional sheet/s if necessary.

Module 4: RA 8749 (Air Pollution) page ____ of ____

Name of Plant:
Reference No:

MODULE 5: P.D. 1586

Ambient Air Quality Monitoring (if required as part of ECC conditions)
Description/Location
of Monitoring N/A
Station
Noise ________ ________ ________ ________
CO NOx Particulates (name) (name) (name) (name)
DATE Level
(mg/Ncm) (mg/Ncm) (mg/Ncm)
(dB) (mg/Ncm) (mg/Ncm) (mg/Ncm) (mg/Ncm)
N/A

(Please accomplish one table per monitoring station.)

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)

N/A

(Please accomplish one table per sampling station.)

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

Name of Plant:
Reference No:

Other ECC Conditions

Status of Compliance
ECC Condition/s Actions Taken
Yes No
1. That stock from civil works shall be
placed away from drainage routes The materlas, stockpiles
and/or creeks and proper disposal of from civil works are placed
the same shall be placed. Likewise,
stockpiling of construction materials  in the safety area and away
from the drainage routes or
(eg. sand and gravel) shall not cause creek and properly
traffic hazards or nuisance to disposed
pedestrians/passer-by.
2. That a greenline and cistern shall be
installed to maximize recycling,
The cistern installed
distribution and utilization of used
water and to store and capture rain  already, present in the
station area
water as additional measures in water
resources management, respectively;
3. That at least two (2) monitoring wells
shall be established at strategic Not applicable in our area,
location to regular monitor possible the checking of leaks can
incidence of ground/ water
contamination from the product leaks
 be found in the check valve
if ever ther is leaking of
and submit regularly result of water products
analysis to EMB.
4. That the proponent shall observe
good vegetation practices, proper
land use and sound soil management
by undertaking a tree-planting
activity along the periphery of the
project site with the appropriate tree
species to serve as buffer for dust and
 Placed flowers in the pots
and green plants
noise and improvement of aesthetics
and in support of the National
Greening Program of the
Government.
5. That all other mitigating measures
indicated in the submitted Initial
Environmental Examimation (IEE),
Checklist and other form of
mitigation ang preventive measures  Complied

be implemented throughout the

operation cycle to prevent/ minimize
negative environmental impacts;
6. The proponent’s operations shall
conform with the provisions of RA
6969 (Toxic substances and
Awareness and help to
Hazardous and Nuclear Waste
Control Act of 1990), RA 9003
(Ecological Solid Waste Management
 protect the environment,
application of the said law
to protect our environment
Act.), RA 8749 (Phil. Clean Air Act
of 1999) and other environmental
laws;
7. That a quarterly Self- Monitoring
Report (SMR) shall be submitted to
this Office for validation within
 Submit reports with
attachment

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

Name of Plant:
Reference No:

fifteen (15) calendar days after the

end of each quarter and a Compliance
Monitoring Report (CMR) shall be
submitted semi-annually as an
attachment of the second and fourth
quarter SMR’s constituting as
Module 5, together with the
operations quarterly production
reports;
8. That in case there is an adverse
impact caused by the project, all
activities causing the same shall be
stopped and remedial measures shall  Safety and precautions by
the management
be affected and his office shall be
informed immediately;
9. In case of abandonment, the
proponent shall notify this office Noted that if this
within three (3) months prior to the
abandonment and the proponent shall  establishment is closed a
direct notice or letter shall
submit its abandonment mitigation be sent to the office
plan;
10. That this Certificate shall
automatically expire if the project
ceases to operate for more than five
(5) years or fails to start within five
 Monitoring & checking of
expiration of certificate
(5) years from issuance
11. No other activities should be
undertaken other than what was
stipulated in the IEE document.
Should there new any expansion of
the project, these same conditions and  Awareness and constant
checking if ECC and
restrictions shall be made subject to a
new Environmental Impact
Assessment; and
12. In case of transfer of ownership of
this project, these same conditions
and restrictions shall apply and the Noted by management and
transferee shall be required to notify
the EMB Regional Office concerned
 reviewing conditions of
ECC
within fifteen (15) days of such
transfer of ownership.
13. That the proponent shall conduct
continuously an Information
Education Communication (IEC)
Campaign to the surrounding Inform and remind the staff
community to inform them of the
environmental impacts and  about the ECC, the laws
that is covered by ECC
corresponding mitigating/ enhancing conditions
measures prior and during the
implementation of the proposed
project.
14. That this certificate shall cover the
Gasoline Refilling and Servicing
Station Project with a maximum fuel
storage capacity of 40,000 liters,  Present in the area, except
the services
confined within a 385 square meters a
lot area acquired by the proponent

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

Name of Plant:
Reference No:

through Contract of Lease. The

facilities and structure include: (1)
service bay, (2) pumping/ refilling
stations, two dispensing pump for
fuel storage tank, (1) stand-by power
utility ;
15. That the proponent shall observe
good vegetation practices, proper
land use and sound soil management
by undertaking a tree- planting
activity. In the event that a natural
tree shall be affected by the project,
the proponent shall replace each tree
with one hundred (100) seedlings of
 Placed more green plants in
the vicinity
indigenous species to be planted in a
watershed within or nearby the
locality as provided in Executive
Order 23 dated February 05, 2011
and its implementing guidelines.
16. That all permits and clearances shall
be regularly secured from the Checking all the permits
concerned national and local offices
prior and during the project
 and processed renewal
before the expiration dates
implementation
17. That on-the-spot monitoring and
inspection can be initiated by the Noted, all the evaluators
EMB-13 anytime to check
compliance to the above stipulations
 from EMB are welcome in
our office for evaluation

18. That the DENR EMB is not

The management is already
accountable to any untoward incident
that may happen to the project caused
by force majeure, structural defects or
 aware and taken the
responsibilities the outward
incident that may happened
whatever cause;
19. The enclosure for stationary noise
generating machineries shall be Secures permits and the
provided in order to control noise
pollutions. Exhaust noise generation  staff are being aware of
noise pollution the cause
machineries shall pass the DENR and its effect
standard;
20. That good housekeeping and sanitary
practices shall be observed at all
times throughout the lifespan of the  Keep the station neat and
clean
project;
The designated PCO not
21. That proponent shall employ a already connected at the
Pollution Control Officer (PCO) in company since March
accordance with RA 8749 and RA 2019. The proponent
9275 particularly DA 2014-02, who
shall handle the environmental
 already provide designated
person that will be
aspects of the project, which shall attending on the next
have the following responsibilities: schedule of seminar for
PCO

Please use additional sheet/s if necessary.

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

Name of Plant:
Reference No:

Environmental Management Plan/Program

Status of
Enhancement/Mitigation Measures Implementation Actions Taken
Yes No
1. Share the important and proper
segregation of the garbage  Actual segregation by the
staff
2. more plant is present in the vicinity for
preventing the heat, maintain cleanliness
within the area
 Maintain and remind the
staff, imposed fines
3. Conserve water by using the cistern for
washing the bathroom area, and for cleaning
purposes
 Installed cistern

4.
5.
6.
Please use additional sheet/s if necessary.

Solid Waste Characterization/Information:

Average Quantity of Total Quantity of Solid
Solid Wastes Generated 5 sacks Wastes Generated this 5 sacks
per month Quarter
Average Quantity of Total Quantity of Solid
Solid Wastes Collected 15 sacks Wastes Collected this 15 sacks
per month Quarter
Entity in charge of
LGU
collecting solid wastes

Brief Description of
Solid Waste SEGREGATION IS PRESENT IN THE PREMISES. GARBAGE IS
Management Plan (e.g., SEPARATEDBY DIFFERENT GARBAGE BIN IN DIFFERENY
waste reduction, CLASSIFICATIONS.
segregation, recycling)

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

Name of Plant:
Reference No:

MODULE 6: OTHERS

Accidents & Emergency Records

Findings and
Date Area/Location Actions Taken Remarks
Observation

N/A

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

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

Done this ___________________, in _Butuan City, Agusan del Norte___.

SARAH MAE DUHAC

Name/Signature of PCO
RETLY G. MANANSALA
Name/Signature of CEO

SUBSCRIBED AND SWORN before me, a Notary Public, this ________ day of
______________________, affiants exhibiting to me their Community Tax Receipts:

Name CTR No. Issued at Issued on

_____________________ _____________ _______________ ______________
_____________________ _____________ _______________ ______________

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

Name of Plant:
Reference No:

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