Department of Environment and Natural Resources Environmental Management Bureau
Department of Environment and Natural Resources Environmental Management Bureau
Department of Environment and Natural Resources Environmental Management Bureau
Reference No:
(to be filled up by DENR only)
e-mail address
CEO/President. ___
Tel #: Fax #: ___
e-mail address: ___
Responsible Officer/s:
Plant Manager: ___
Tel #: Fax #: ___
e-mail address: ___
Name. ___
Pollution Control
Tel #: Fax #: ___
Officer
e-mail address: ___
We hereby certify that the above information are true and correct.
DENR Permits/Licenses/Clearances
Environmental
Permits Date of Issue Expiry Date
Laws
A/C No.
P.D. 984
PO No.
ECC 1
PD 1586 ECC 2
ECC 3
DENR
Registry ID
CCO Registry
RA 6969 Importer
Clearance No
Permit to
Transport
A/C No.
RA 8749
PO No.
Operation
Operating hours/day Operating days/week # of shift/day
Average
Maximum
Operation/Production/Capacity:
Average Daily
Total Output this Quarter
Production Output
Total Water Consumption Total Electric
this Quarter (cubic Consumption this Quarter
meters) (KwH)
Please use additional sheet/s if necessary
MODULE 2: RA 6969
For producers
Average Daily
Total Output this Quarter
Production Output
Quantity of Stock Quantity of Stock
Inventory (Start of Inventory (End of
Quarter) Quarter)
Name of Buyer Quantity Date of Purchase
Other Information:
Manner of handling storage on-site Treatment on-site
hazardous wastes storage off-site Treatment off-site
Chemical Substitute Yes (please attach copy if not submitted/included in previous report/s or had been revised)
Plan 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
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: ___
HW No,: ___
HW Details Qty of HW Treated: Unit: ___
TSD Location: ___
Name: ___
Storage
Method: ___
(if any)
New/Additional
Investments in WTP
(Description)
Cost of New/Add
Investments
Outlet No.
Summary of APSE/APCF
Process Equipment Location # of hrs of operations
1.
2.
3.
4.
Fuel Burning Quantity # of hrs of
Location Fuel Used
Equipment Consumed operations
1.
2.
3.
4.
5.
6.
Pollution Control Facility Location # of hrs of operations
1.
2.
3.
4.
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
1.
2.
3.
4.
5.
6.
Please use additional sheet/s if necessary.
1.
2.
3.
4.
5.
6.
Please use additional sheet/s if necessary.
Brief Description of
Solid Waste
Management Plan (e.g.,
waste reduction,
segregation, recycling)
MODULE 6: OTHERS
Personnel/Staff Training
# of Personnel
Date Conducted Course/Training Description
Trained
I hereby certify that the above information are true and correct.
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: