Department of Environment and Natural Resources

Environmental Management Bureau

Reference No:
G E N E R A L I N F O R M AT I O N S H E E T

Name of the
Establishment/Facility
Establishment/Facility
Address
(NOT the company of head
office)
Name of
Owner/Company
Street # & Street Name: (Same as above) ___
Address
(if address is not the same as Barangay: City/Municipality: ___
previous address)
Province:

Phone Number Fax Number

e-mail address

Philippine Standard Industry Classification Code No.

Type of Business/
Philippine Standard Industry Descriptor: ___
Industry Classification
___

CEO/President:
Tel #: Fax #:
e-mail address:
Responsible Officer/s:
General Manager - Operations:
Tel #: Fax #:
e-mail address:

Name.
Pollution Control
Tel #: Fax #:
Officer
e-mail address:

 single proprietorship  partnership

Legal Classification  private domestic corporation  government corporation

X Multi-national  ___

We hereby certify that the above information are true and correct.

Name/Signature of PCO Name/Signature of General Manager - Operations

Page 1 of 18
NSG Micro Optics Philippines, Inc. Reference No:

Department of Environment and Natural Resources

Environmental Management Bureau

Q U A R T E R LY S E L F - M O N I T O R I N G R E P O R T

MODULE 1: GENERAL INFORMATION

Name of the Plant
Please provide the necessary revised, corrected or updated information not contained in your General
Information Sheet

(use additional sheet/s if necessary)

DENR Permits/Licenses/Clearances
Environmental
Permits Date of Issue Expiry Date
Laws
A/C No.
P.D. 984
DP No.

ECC 1

PD 1856 ECC 2

ECC 3
DENR
Registry ID
CCO Registry
RA 6969 Importer
Clearance No
-
Permit to
Transport
A/C No.
RA 8749
PO No.
NSG Micro Optics Philippines, Inc. Reference No:

Operation
Operating hours/day Operating days/week # of shift/day
Average
Maximum

Operation/Production/Capacity:
Average Daily Production
Total Output this Quarter
Output
Total Water Consumption Total Electric
this Quarter (cubic Consumption this Quarter
meters) (KwH)
Please use additional sheet/s if necessary
NSG Micro Optics Philippines, Inc. Reference No:

MODULE 2: RA 6969

A. CCO Report (please accomplish this section for each chemical/substance)

Common Name/IUPAC/CAS Index Name. ___

CAS No.: ___
Trade Name: ___

For importers only:

Import
Quantity Date of Quantity Country of Country of
Clearance Port of Entry
Requested Arrival Received* Origin Manufacture
No.

Total Quantity Requested Total Quantity Received

(annual) (annual)
* attach copy/s of Bill of Lading

For distributors (importers/non-importers)

Name of Client License No. Quantity Date of Distribution

Total Quantity Distributed

For non-importer users:

Name of Distributor Quantity Date of Purchase

Total Quantity Purchased from Distributor

NSG Micro Optics Philippines, Inc. Reference No:

For producers

Used in Production (please fill up only if chemical/substance is not main product)

Average Daily Production
Total Output this Quarter
Output
Average Quantity Used Total Quantity Used this
per month Quarter
Describe any changes in Production/Process/Operations:

Average Daily Production

Total Output this Quarter
Output
Quantity of Stock Quantity of Stock
Inventory (Start of Inventory (End of
NSG Micro Optics Philippines, Inc. Reference No:
Quarter)
Quarter)
Name of Buyer Quantity Date of Purchase

Total Quantity Sold

Stock Inventory/Waste Chemical Generated:

Average Quantity of Total Quantity of Waste
Waste Chemical Chemical Generated this
Generated per month Quarter
Quantity of Stock Quantity of Stock
Inventory (Start of Inventory (End of
Quarter) Quarter)

Other Information:
 storage on-site  Treatment on-site
Manner of handling
hazardous wastes
 storage off-site  Treatment off-site

 Yes (please attach copy of revised plan)

Changes in Safety
Management System
 No

 Yes (please attach copy if not submitted/included in previous report/s or had been revised)
Chemical Substitute
Plan
 No
NSG Micro Optics Philippines, Inc. Reference 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: Drum ___

ID: Name: ___

Transporter
Date: ___

ID: Name: ___

Treater
Method: Date: ___

ID: Name: ___

Disposal
Date: Date: ___

HW No.: ___
HW Details Qty of HW Treated: Unit: Tons ___
TSD Location: ___

Name: ___
Storage
Method: ___

ID: Name: ___

Transporter
Date: ___

ID: Name: ___

Treater
Method: Date: ___

ID: Name: ___

Disposal
Date: Date: ___
NSG Micro Optics Philippines, Inc. Reference No:

HW No.: ___
HW Details
Qty of HW Treated: Unit: ___
TSD Location: ___

Name: ___
Storage
Method: Drum ___

ID: Name: ___

Transporter
Date: ___

ID: Name: ___

Treater
Method: Date: ___

ID: Name: ___

Disposal
Date: Date: ___

HW No,: ___
HW Details Qty of HW Treated: Unit: Tons ___
TSD Location: On-site- ___

Name: ___
Storage
Method: Drum ___

ID: Name: ___

Transporter
Date: ___

ID: Name: ___

Treater
Method: Date: _

ID: Name: ___

Disposal
Date: Date: ___
NSG Micro Optics Philippines, Inc. Reference No:

HW No,: ___
HW Details
Qty of HW Treated: Unit: Tons ___
TSD Location: ___

Name: ___
Storage
Method: ___

ID: Name: ___

Transporter
Date: ___

ID: Name: ___

Treater
Method: Date: ___

ID: Name: ___

Disposal
Date: Date: ___

On-Site Self Inspection of Storage Area:

Corrective Action Taken
Date Conducted Premises/Area Inspected Findings & Observations
(if any)
NSG Micro Optics Philippines, Inc. Reference No:

C. Hazardous Wastes Treater/Recycler

HW Stored and/or Untreated as of End of Quarter:

Type of
Transport Storage Time Table
Wastes Date of
HW Number Permit/Date Valid until Quantity Container/ for
Generator Transport
of Issue # of Treatment
containers

HW Treated and/or Recycled as of End of Quarter:

Type &
Type of
Transport Quantity of
Type of Wastes Date of Treatment or
HW Number Permit/Date Quantity Recycled or
Wastes Generator Transport Recycling
of Issue Treated
Process
Product

Residual Wastes Generated from the Treatment and/or Recycling Operation:

Process by Type of
which the Storage Disposal Time Table for
Type of Wastes HW Number Quantity
Wastes is Container/ Option Disposal
Generated # of containers
NSG Micro Optics Philippines, Inc. Reference No:

MODULE 3: P.D. 984 (Water Pollution)

Water Pollution Data

Domestic wastewater Process wastewater
(cubic meters/day) (cubic meters/day)
Cooling water Others: ___________
(cubic meters/day) (cubic meters/day)
Wash water, equipment Wash water, floor
(m3/day) (cubic meters/day)

Record of Cost of Treatment (Separate entries for separate facilities)

Month 1 Month 2 Month 3
Person employed, (# of
employees)
Person employed, (cost)
Cost of Chemicals used
by WTP
Utility Costs of WTP
(electricity & water)
Administrative and
Overhead Costs
Cost of operating in-
house laboratory
New/Additional
Investments in WTP
(Description)
Cost of New/Add
Investments

WTP Discharge Location

Outlet
Location of the Outlet Name of Receiving Water Body
Number
1
2
3
4
5
NSG Micro Optics Philippines, Inc. Reference No:

Detailed Report of Wastewater Characteristics for Conventional Pollutants

Outlet No.

DATE Effluent Oil & ________

BOD TSS Temp rise (name)
2007 Flow Rate Color pH Grease
(mg/L) (mg/L) (ºC)
(m3/day) (mg/L)
(unit)

Please fill-up/accomplish separate form/s for other outlet/s.

Detailed Report of Wastewater Characteristics for Other Pollutants

NSG Micro Optics Philippines, Inc. Reference No:

Outlet No.
Effluent
DATE
Flow Rate
As Cd Pb Hg Ba Cr Tl
2007 Mg/L Mg/L mg/L mg/L mg/L mg/L Mg/L
(m3/day)

Please fill-up/accomplish separate form/s for other outlet/s.

Please use additional sheet/s if necessary.
NSG Micro Optics Philippines, Inc. Reference No:

MODULE 4: R.A. 8749 (Air Pollution)

Summary of APSE/APCF
Process Equipment Location # of hrs of operations

Fuel Burning Quantity # of hrs of

Location Fuel Used
Equipment Consumed operations

Pollution Control Facility Location # of hrs of operations

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
NSG Micro Optics Philippines, Inc. Reference No:

Detailed Report of Air Emission Characteristics

Description/Location
STANDBY-GENERATOR
of PCF
________ ________ ________ ________
Flow Rate CO NOx Particulates (name) (name) (name) (name)
DATE
(Ncm/day) (mg/Ncm) (mg/Ncm) (mg/Ncm)
(mg/Ncm) (mg/Ncm) (mg/Ncm) (mg/Ncm)

Please fill-up/accomplish separate form/s for other PCF/s.

Please use additional sheet/s if necessary.
NSG Micro Optics Philippines, Inc. Reference No:

MODULE 5: P.D. 1586

Ambient Air Quality Monitoring (if required as part of ECC conditions)

Description/Location
of Monitoring Station
________ ________ ________ ________
Noise Sox NOx TSP (name) (name) (name) (name)
DATE
Level (dB) (mg/Ncm) (mg/Ncm) (mg/Ncm)
(mg/Ncm) (mg/Ncm) (mg/Ncm) (mg/Ncm)

(Please accomplish one table per monitoring station.)

Ambient Water Quality Monitoring (if required as part of ECC conditions)

Description/Location
Of Sampling Station
________ ________ ________ ________ ________ ________ ________ ________
(name) (name) (name) (name) (name) (name) (name) (name)
DATE
(unit) (unit) (unit) (unit) (unit) (unit) (unit) (unit)

(Please accomplish one table per sampling station.)

Other ECC Conditions

NSG Micro Optics Philippines, Inc. Reference No:

Status of Compliance
ECC Condition/s Actions Taken
Yes No

Please use additional sheet/s if necessary.

Environmental Management Plan/Program

Status of
Enhancement/Mitigation Measures Implementation Actions Taken
Yes No

Please use additional sheet/s if necessary.

Solid Waste Characterization/Information:

Average Quantity of Total Quantity of Solid
Solid Wastes Generated Wastes Generated this
per month Quarter
Average Quantity of Total Quantity of Solid
Solid Wastes Collected Wastes Collected this
per month Quarter
Entity in charge of
collecting solid wastes
Brief Description of Solid
Waste Management Plan
(e.g., waste reduction,
segregation, recycling)
NSG Micro Optics Philippines, Inc. Reference No:

MODULE 6: OTHERS
Accidents & Emergency Records
Findings and
Date Area/Location Actions Taken Remarks
Observation

Personnel/Staff Training
# of Personnel
Date Conducted Course/Training Description
Trained

I hereby certify that the above information are true and correct.

Done this _____________________, in ____________________________.

Name/Signature of PCO Name/Signature of GM – Operation

SUBSCRIBED AND SWORN before me, a Notary Public, this __________________

______________________, affiants exhibiting to me their Community Tax Receipts:

Name CTR No. Issued at Issued on

Doc. No. : ________

Page No. : ________
Book No.: ________
Series of : ________