AFFIDAVIT

REPUBLIC OF THE PHILIPPINES )

_________________________________) s.s.

I, ___________________________________________________ of legal age,

single/married, residing at _________________________________________, the
___(designation)_____ of ____(Name of Establishment)____ located at
__________________; after being sworn in accordance with law, depose and say
that:

1. I am an applicant for registration as Hazardous Waste Generator

pursuant to Section 26 of RA 6969 (Toxic Substances and Hazardous
and Nuclear Wastes Control Act of 1990);

2. I am aware and understand all the duties, responsibilities and

accountability to be imposed upon me and my establishment by such
application and as such will be liable for all the damages incurred and
for any untoward incident during its actual operation, during generation
of hazardous wastes and shall be wholly responsible for spill response
and clean-up during spills or accidental leaks including clean-up or
remediation of affected areas and compensation for any environmental
damage caused by such spill or leakage of hazardous wastes;

3. I attest to the truth, accuracy and genuineness of all the information,

documents and records contained and attached to this application and
that I and my establishment shall be liable for any misrepresentation,
fraudulent declaration and all its consequences;

4. I am executing this affidavit as a proof of good faith in complying with the

requirements for securing the abovementioned registration.

IN WITNESS WHEREOF, I have hereunto set my hand this _______day of

___________________ 20__ in ______________________.

____________________________
Signature over printed name
of affiant