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Republic of the Philippines DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCES ENVIRONMENTAL MANAGEMENT BUREAU Office of the

Republic of the Philippines

DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCES

ENVIRONMENTAL MANAGEMENT BUREAU

Office of the Regional Director

Region IX, Western Mindanao

2/F Pastoriza Bldg., Datoc St., Gatas District, Pagadian City

(062) 215-4137

Application for Discharge Permit

New

Renewal

Renewal

 

Expiry Date

 

TIN

 

Application No.

   
Republic of the Philippines DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCES ENVIRONMENTAL MANAGEMENT BUREAU Office of the

INSTRUCTION: Fill in all appropriate white spaces. Mark all appropriate boxes with an “X”. NOTE: Failure to complete this form may be sufficient ground for disapproval of the permit application.

GENERAL INFORMATION

Name of Establishment/Plant Est. Code Year Est. Plant Address: No. & Street Name Barangay City or
Name of Establishment/Plant
Est. Code
Year Est.
Plant Address: No. & Street Name
Barangay
City or Municipality
Province
Type of Industry
Name of PCO
Accreditation Date
Tel. No. & Cel. No.
Fax No.
Legal Classification
Proprietorship
Private Corporation
Multinational
Others, specify
Ownership Terms (%)
Private
%
Foreign
%
Government
%
EMPLOYMENT AND OPERATION INFORMATION
Total Employment (number of workers) in the factory:
Production
Non-Production
Production Time: Number of Hours/day
Number of days/month
Number of months/year

SOURCES OF WATER SUPPLY AND WASTEWATER GENERATION

Sources of Water Supply Monthly Ave. Vol. (m 3 ) Daily Ave. Vol. (m 3 )
Sources of Water Supply
Monthly Ave. Vol. (m 3 )
Daily Ave. Vol. (m 3 )
Generating Process
Estimated Flow
(m 3 )
MWSS
(Please
attach
Process Water
water bills)
Local
Water
District
Washing/Cleaning of Process Water
(Please attach water bills)
Deep wells
Cooling
Surface waterbodies, river,
creek, etc.
Domestic
Others
Recycled/Reuse
Others
(drinking
water,
gardening,
evaporation,
leaks,
product
component, etc.)
Total Water Consumption
Total
Volume
of
Discharge
Wastewater
Dwelling Units Information (hotels, condominium, restaurants, malls, etc)
Total Floor Area
No. of Bedrooms
No. of Guest/Year
Total Area for Dwelling Unit (m 2 )
No. of Restaurants/Dining Unit

PRODUCTION INFORMATION

   

Product 1

 

Product 2

 

Product 3

Product Name

     

Actual Production

     

Actual Production in the Previous Year

     

Type of Process

Batch Continuous

Batch

Continuous

Batch Continuous

Batch

Continuous

Batch Continuous

Batch

Continuous

Note: **Please use generic product name, not in brand names, in metric tons of product, carbonated drinks and beer (m 3 ) Except for the following substances: hog raising (heads), slaughtering/preserving

Water Pollution Information

 

Location &

Name of the

Estimated Ave.

Estimated Ave.

Estimated

Average Load

Outlet Number

Distribution of

Receiving body if

BOD/TSS conc.

Rate of Discharge

BOD/TSS

Outlet

not discharging in the lake

(mg/L)

(m 3 /day)

(kg/day)

1

           

2

3

Total

Name of Laboratory Performing Analysis:

 

Address of Laboratory:

 

Date of Sampling:

 

Date of Analysis:

Method of Sampling:

 

Vicinity Map (The map should show relative location of the establishment with respect to existing structures, landmarks, rivers, lakes and other water

bodies, etc

..

Use scale to fit into the frame below.)

PRODUCTION INFORMATION Product 1 Product 2 Product 3 Product Name Actual Production Actual Production in the

Fixed Fee Official Receipt Number:

__________________________________

Date of Issue:

___________________

I hereby certify that the above information are true and correct to the best of my knowledge. Done this

day of

of 20____.

______________________________________

________________________ Chief Executive Officer

SUBSCRIBED AND SWORN to before a Notary Public. This

Community Tax Receipt

day of ____________________

Affiant exhibiting to me his/her on ________________________.

________________.

No. _________________________________

______________

issued at

Doc.

No .________

Page

No .________

Book No .________ Series of ________

_________________________________ Notary Public

REQUIREMENTS FOR APPLICATION FOR A WASTEWATER DISCHARGE PERMIT

FOR NEW APPLICATION:

Name of Establishment:

Address:

A) Engineer’s Report

  • 1. Vicinity Map

  • 2. Nature of Project or Business

  • 3. Production Capacity Quantity or Volume and Generic Name/s of Product/s

  • 4. Nature and character of the applicant’s wastewater and its physical and chemical composition

  • 5. Total daily volume of discharge of raw wastewater

  • 6. Treatment process and estimated treatment efficiency

  • 7. Total daily volume of water consumption and discharge of final treated wastewater or effluent

  • 8. The name of receiving body of water and its official water classification and in case of land discharge, the nearest receiving body of water and its official water classification

  • 9. Information on flow measurement equipment and procedure

    • 10. Pollution prevention/Environmental System plan or program

    • 11. DENR ID Number as hazardous waste generator (if applicable)

    • 12. Statement of the cost incurred in the installation and maintenance of wastewater treatment facility, if any

    • 13. Quality and quantity of abstracted water

    • 14. Copy of ECC or CNC (if applicable)