LAGUNA LAKE DEVELOPMENT AUTHORITY

National Ecology Center, East Avenue

Diliman, Quezon City
Tel. Nos.: 332-2346, 376-4039, 376-4072, 376-4049, 376-4061

CLEARANCE APPLICATION FOR DEVELOPMENT PLAN/PROGRAM/PROJECT IN

THE LAGUNA de BAY REGION

LLDA CLEARANCE AMENDMENT EXEMPTION EXPANSION

PART I – APPLICANT INFORMATION

Name of Establishment: _______________________________________________________

Tax Identification Number (TIN): __________________________ Year Established: ___________

Business Address:
Number and Street: _______________________________ Barangay: ______________________
City/Municipality: _________________________________ Province: _______________________
GPS Coordinates: (Latitude) ________________________ (Longtitude) _____________________

Name & Location of Project/Development:

Project Name (if any): ____________________________________________________________
Number and Street: _______________________________ Barangay: ______________________
City/Municipality: _________________________________ Province: _______________________

Chief Executive Officer of the Establishment:

Name: ___________________________________ Title/Designation: ______________________
Tel #: ____________ Fax #: _____________ Cel #: _____________ email add: ______________

Applicant’s Authorized Representative/Pollution Control Officer:

Name: ____________________________________Title/Designation: ______________________
Name of Firm: __________________________________________________________________
Number and Street: _______________________________ Barangay: ______________________
City/Municipality: ________________ Province: _______________Tel. # :___________________
Fax #: _________________ Cel. #: ________________ email add: ________________________

PART II – BUSINESS ACTIVITY DESCRIPTION

I. Business Activity: _______________________________

Production Capacity (allowed per ECC): ________________________________________
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LLDA-CPD-Form 01 Issue Date: November 2015 Issue No.: 02

 A. Industrial Establishment/Infrastructure Projects and other similar project
Capital Investment (Authorized Capital Stock): PhP________________________
Total Project Cost: _____________________________
B. Agro-Industrial Establishment
Capacity (Maximum No. of Heads): ___________________________________________

C. Housing Development, Institution, Hospital, Commercial Establishments, Parks,

Golf Course warehouse/storage facilities, etc.
Gross Floor Area (sq.m): __________________ Total Lot Area (sq.m): ________________
For Townhouses/Villas/other cluster housing units (total no. of units): _________________

D. Other Projects (Land Transport Terminal/Parking Areas)

No. of vehicle slots: ___________________

II. Employment and Operation Information

Total Employment (number of workers) Operational Schedule/Time
Production: ________________ No. of hours/day: _________ shifts/day: _____
Non-Production: ____________ No. of days/month: _______________

PART III – WATER SUPPLY, WASTEWATER GENERATION, TREATMENT AND DISPOSAL

Sources of Water Supply
MWSI/MWCI ( ) Local Water District ( ) Deepwell ( ) Laguna de Bay ( )
Rivers ( ) Others ( )
Total Water Consumption (m3/day): ____________________
Wastewater Generation, Treatment and Disposal
Total Volume of Wastewater Discharge (m3/day): ___________________
Method of Treatment: _________________________________________
Disposal: ____________________________________________________

I certify that the information above are true, complete and accurate to the best of my knowledge.

_________________________________________ _______________________________
Signature of Representative/Pollution Control Officer Signature of Chief Executive Officer
Date: _________________________ Date: ________________________________

SUBSCRIBED AND SWORN to before me a NOTARY PUBLIC, this ______ day of

________________, affiant exhibiting to me his/her Community Tax Receipt No. _________________ issued
at ________________ on ___________________

NOTARY PUBLIC
Doc. No. ________
Page No. ________
Book No. ________
Series No. ________

All information contained in this application form will be held strictly confidential.

LLDA-CPD-Form 01 Issue Date: November 2015 Issue No.: 02