Self-Monitoring Report (SMR) System

For _____________ Quarter of CY _________________

Name of Company: __________________________________________________

Address:___________________________________________________________

Environmental Management Bureau

DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCES

QUARTER ______ YEAR _______

Module 1: General Information page ____ of ____
 GENERAL INFORMATION SHEET

Name of the
Establishment/Facility

Establishment/Facility Street # & Street Name: ____________________________________

Address Barangay: ___ City/Municipality: ____________________
(NOT the company of head
office) Province:
Name of
Owner/Company

Street # & Street Name: _________________________

Address
(if address is not the same Barangay: City/Municipality: __
as previous address)
Province:

Phone Number Fax Number

e-mail address

Type of Business/ Philippine Standard Industry Classification Code No. _____

Industry
Classification Philippine Standard Industry Descriptor: ______

CEO/President. ____
Tel #: _________ Fax #: _______________

Responsible e-mail address:

Officer/s: Plant Manager: ______
Tel #: ___________ Fax #: ______________
e-mail address: _______

Name. _______ ____

Pollution Control
Officer Tel #: Fax #: __________
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.

_______________________________ __________________________
Name/Signature of CEO/President Name/Signature of PCO

QUARTER ______ YEAR _______

Module 1: General Information page ____ of ____
 Department of Environment and Natural Resources
Environmental Management Bureau
Period covered_______________________

MODULE 1: GENERAL INFORMATION

Name of the Plant
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
RA 9275 PO No.

CNC

PD 1586 ECC 2

ECC 3
DENR
Registry ID
CCO Registry
RA 6969 Importer
Clearance No
Permit to
Transport
RA 8749 PO No.

QUARTER ______ YEAR _______

Module 1: General Information page ____ of ____
Operation
Operating hours/day Operating days/week # of shift/day
Average
Maximum

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

For All Establishments

Total Raw Materials Processed this Quarter
(tons)
Total Production Output this Quarter (tons)

For Gasoline Refilling Stations

Total Gasoline Delivered for this Quarter
Total Gasoline Dispensed for this Quarter

QUARTER ______ YEAR _______

Module 1: General Information page ____ of ____
MODULE 2: RA 6969

A. CCO Report (please accomplish this section 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

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

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

 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 ____

B. Hazardous Wastes Generator

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

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
Method: 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: ___

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

On-Site Self Inspection of Storage Area:
Premises/Area Findings & Corrective Action
Date Conducted
Inspected Observations Taken (if any)

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

C. Hazardous Wastes Treater/Recycler

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

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

MODULE 3: RA 9275 (Water Pollution)

Water Pollution Data

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

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

Month 1 Month 2 Month 3
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

New/Additional
Investments in WTP
(Description)

Cost of New/Add
Investments

WTP Discharge Location

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

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

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

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

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

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

Summary of APSE/APCF
Process Equipment Location # of hrs of operations

Fuel Burning Quantity # of hrs of

Location Fuel Used
Equipment Consumed operations

# of hrs of
Pollution Control Facility Location
operations

Cost of Treatment
Month 1 Month 2 Month 3
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

Improvement or
modification, if any.
(Description)

Cost of improvement of
modification

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

Detailed Report of Air Emission Characteristics
Description/Location
of PCF
_______ _______
________ ________
Flow Rate CO NOx Particulates (name) _ _ (name)
DATE (name) (name)
(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 4: RA 8749 (Air Pollution) page ____ of ____

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)
DATE (name) (name)
Level (dB) (mg/Ncm) (mg/Ncm) (mg/Ncm)
(mg/Ncm) (mg/Ncm)
(mg/Ncm) (mg/Ncm)

(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)

(Please accomplish one table per sampling station.)

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

Other ECC Conditions
Status of Compliance
ECC Condition/s Actions Taken
Yes No

1.
2.
3.
4.
5.
6.
7.
Please use additional sheet/s if necessary.

Environmental Management Plan/Program

Status of
Enhancement/Mitigation Measures Implementation Actions Taken
Yes No

1.
2.
3.
4.
5.
6.
7.
Please use additional sheet/s if necessary.

Solid Waste Characterization/Information:

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

Brief Description of
Solid Waste
Management Plan
(e.g., waste reduction,
segregation, recycling)

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

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

Done this _________________________, in ________________________.

__________________
Name/Signature of PCO
_______________
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

___________ ________________________________________________

___________________________________________________________________

Preparation and Submission of SMR 17