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Republic of the Philippines

Region 10, Macabalan, Cagayan de Oro City


) New


) Renewal


) Change of Ownership

1. Name of Applicant : _______________________________________________________________
2. Position/Designation of Applicant: ____________________________________________________
3. Name of Firm/Establishment: _______________________________________________________
4. Office Location: __________________________________________________________________
5. Telephone No (s): ________________________________________________________________
6. Plant Location: __________________________________________________________________
7. Mailing Address: _________________________________________________________________
8. Capitalization: Authorized: _____________________________ Paid Up: ____________________
9. Name of Accredited/Appointed Pollution Control Officer: _________________________________
10. Nature of Business: _______________________________________________________________
11. List of Air Pollution Source Equipment (APSE) Process (es) and corresponding Air Pollution Control
Facility (ies) (APCP) covered by the permit application. (Use additional sheet if necessary)

Date Installed

(e.g. One (1) unit 500hp Boiler with scrubber, 10 ton cap. Reverberatory
One (1) unit 300kW Diesel Engine Generator Set w/ Muffler



12. Maintenance and Operating Cost of Air Pollution Control Facility(ies) (APCF) or APSE
a. Power: __________________________________
b. Labor : __________________________________
c. Replacement Parts: ________________________
13. For new permit applications, total cost of all APCFs or APSEs: (including construction cost covered
by the same)
CERTIFIED CORRECT: _________________________________
Signature of applicant
Permit Fee: _________________
Filing Fee:
Php 55.00
Php 10.00

O.R. No. _____________ Date Issued: __________
O.R. No. _____________ Date Issued: __________
O.R. No. _____________ Date Issued: __________

SUBSCRIBED AND SWORN before me, a Notary Public, this _____day of _________, affiants
exhibiting to me their Community Tax receipts:
Tax Receipts:


Issued at

Issued on

Requirements for Permit to Operate for New and Modified Sources
An application for permit to operate shall be filed for each source emitting regulated air pollutants. Facilities having more than one source may
group the sources under a single permit application, provided the requirements below are met for each individual source. Applications shall be
made in a format prescribed by the Department through the bureau, field in triplicate copies, together with a copy of the official receipt of the
filling fees and including the following:

The impact analysis shall estimate the resulting ambient air concentrations for all significant pollutants from the facility. if warranted. The designed efficiencies of the air control equipment and the quantities and types of pollutants in the final emissions shall be indicated. . (d. and shall include the existing ambient air concentrations as a baseline. sections. c Environmentally significant source is defined as any source of emissions of hazardous air pollutants included on the list of Priority Chemicals in DAO 1998-58. or fuels with a sulfur content of 1% or more. or any other source that has the potential to emit at least 30 tonnes per year.) The plan and specifications of the installation and its control facilities (preferably in standard size of 50 cm by 90 cm) duly certified by a registered professional mechanical engineer. Appointment/designation of a Pollution Control Officer by the managing head. The plans shall clearly show in adequate detail the agreement.) (d. A large or environmentally significant existing source should be tested twice per year for each year of its operation by the permittee/facility operator to verify its compliance.) (e. Tax Identification Number and/or SEC registration. Where confidential records are involved. Copy of the Certificate of Accreditation of the Pollution Control officer duly issued by the Department. (b.) (b. then the Permit to Operate will require the facility to operate at or below 50% operating capacity. A medium-sized existing source should be tested annually by the permittee/facility operator to verify its compliance. if the facility passes the stack sampling test at 50% operating capacity. a diesel generator rated at 600 to 1. Photocopy of the Environmental Compliance Certificate (ECC) from the Department or Certificate of Non-Coverage (CNC).) The project proponent shall conduct and air quality impact analysis using Bureau-Approved computer dispersion models and techniques. or any source that has the potential to emit at least 10 tonnes per year.) (f. And construction details. a large source is defined as a boiler rated at 251horsepower (HP) or greater.) Copies of Quarterly Self-Monitoring Reports for the immediately preceding year. location and size of the pollution control equipment or facilities. shall be tested twice each year for each year of their operation. All sources using Bunker fuel. Each test shall consist of three sampling runs. they clearly reveal the proposed means and methods for the control of pollution and their expected performance efficiency.) (g. only emission testing shall be required. but less than 100 tonnes per year. Requirements for Renewal of “Permit to Operate” for Existing Air Pollution Sources and Control Installations f (a. when read in conjunction with the plans. of an air pollution regulated under the Act. the estimated types. to emit 100 tonnes or more per year of an air pollutant regulated under the Clean Air Act.249 kW (regardless of its frequency of operation). smelters. the emission rate and annual mass emission objectives. Each test shall consist of three sampling runs. chemical engineer or any appropriate engineer or a combination of any two or all of them as may be required by the Bureau depending upon the nature of the construction. including their accessories.) A vicinity map adequately identifying the street address. to determine if the construction or modification will result in a violation of applicable air quality standard. blended fuels involving Bunker fuel. For example.) An engineering report covering the plant description and operations. but less than 30 tonnes per year. or appointment or designation as such by the Managing Head. Periodic or Routine Compliance Testing of Existing Sources depending on the classification of the installation as provided in Memorandum Circular 2007-003. Thereafter.250 kilowatts (kW) or greater (regardless of its frequency of operation). Certification attesting the specific date when the installation(s) was/were completed/operated. the control facilities.) (h. diesel generators rated at less than 300 kW and other sources that have the potential to emit less than 10 tonnes per year of an air pollutant regulated under the Act. The impact analysis will be used by the Bureau.(a. Official Receipt of Payment. Requirements in the Permit to Operate will be based on operating conditions at the time of the test. the bureau may limit the full disclosure of the same after discussions with the applicant. A small existing source should be tested by the permittee/facility operator once during the first year of its operation to verify its compliance. petrochemical works. concentrations and quantities of all emissions to the atmosphere. Other Existing Sources Not Requiring emission testing for permitting purposes: boilers rated at less than 50 HP. operation or activity sought to be covered by the permit. if any. Each test shall consist of three sampling runs. ferro-alloy and glass-making plants. it should be tested once in every second year. the design criteria. cross.) (c. b medium-sized source is defined as a boiler rated at 100 to 250 HP. shall be based on the results of laboratory and pilot plant scale studies. or any source that has the potential. and the principal emission sources at petroleum refineries. The specification shall be in sufficient detail so that.) Additional requirements pursuant to MC No: 2007-003 for New and Modified sources prior to issuance of regular permit. For large a and environmentally significant b sources permit applicants shall be required emission test and dispersion modeling to demonstrate compliance with the source-specific ambient air quality standards. cement kilns. (c. Each test shall consist of three sampling runs. a diesel generator rated at 599 kW or less (regardless of its frequency of operation). a diesel generator rated at 1. of the location or premises of the installation. of an air pollution regulated under Act. and steel. For medium-sized source c. together with other relevant information. small source is defined as a boiler rated at 99 HP or less. (i.