Republic of the Philippines

Department of Environment and Natural Resources

ENVIRONMENTAL MANAGEMENT BUREAU
Regional Office V
Legazpi City

APPLICATION FOR PERMIT TO OPERATE

For Air Pollution Source and Control Installations
(IMPORTANT: Read the INSTRUCTIONS at the back before accomplishing the form)
TYPE: □ New □ Renewal □Change of Ownership
1. Name and Position of Applicant :

2. Name of Firm/Establishment :

3. Office Address : Tel No. :

4. Plant Location : Tel No. :

5. Capitalization Authorized : Paid Up :

6. Name of Accredited Pollution Control Officer : __________________

Tel No. :

7. Nature of Business :

8. List of Air Pollution Source Equipment (APSE) Process(es) and corresponding Air Pollution Control
Facility(ies) (APCF) covered by the permit.

Description Date Installed

(e.g 500 Hp boiler/scrubber, 10-ton capacity

reverbetory bag house) APSE APCF

a.
b.
c.
e.
f.

9. Maintenance and Operating of APCEs: a. Power :

b. Labor :
c. Replacement Parts :
d. Others (Specify) :

10. For new permit application, total cost of all APCEs (including construction cost) covered by the same :

11. Have you submitted all thee required “SUPPORTING DOCUMENTS” listed at the back?
[ ] Yes [ ] Partially [ ] No

If YES, submit only this application form duly accomplished and indicate in the transmittal letter
that no modification(s) had been made previously submitted documents.

If PARTIALLY or NO, submit all lacking documents respectively. Indicate the partially
submitted in the transmittal letter. (Refer to Item No. 2 of “INSTRUCTION” at the back).

CERTIFIED CORRECT:

__ _____
Signature Over Printed Name

Filing Fee O. R. No. Date

Permit Fee O. R. No. Date
PD 1856 O. R. No. Date
PAB Res 10A O. R. No. Date
 INSTRUCTION FOR FILING APPLICATION

1. This form shall be fully accomplished and the required supporting documents shall be
submitted completely, otherwise the application will be returned.
2. This form and the required supporting documents shall be submitted in duplicate copies
of applicant if the plant/establishment is located in Luzon and in triplicate copies if
located in Visayas and Mindanao and shall be accompanied by a letter of transmittal
addressed to the Regional Director, EMB V.

SUPPORTING DOCUMENTS

1. Engineer’s Report duly signed by a registered Engineer covering the following

a. Process of the plant covering its operations and descriptions;
b. List of Air Pollution Source Equipments (APSE) and its corresponding control
devices (APCF) [including its capacity and usage];
c. Specific Fuel Consumption (L/KW-hr) for generator sets and boilers;
Raw materials capacity (ricemills)
d. Process Flow Diagram of APSE and APCF (including raw materials’ input and
output);
e. Pictures of Air Pollution Source and Control Equipments
f. Environmental Management Plan; and
g. Plant/Machinery Lay-out;

2. Vicinity Map

3. A signed copy of the appointment/designation of the Pollution Control Officer (PCO) of

the applicant together with the following:
a. Application letter for PCO Accreditation;
b. Appointment/ Designation Letter of Pollution Control Officer (PCO) from the
company.
c. Updated Bio-Data of appointed PCO; and
d. Copy of certificates of relevant trainings/seminars attended.

4. Photocopy of Environmental Compliance Certificate (ECC) or Certificate of Non-Coverage

(CNC); and

5. Certificate of Zoning Clearance/Locational Clearance

SUBSCRIBED AND SWORN TO before me this ____________________________ day of

__________________200 . Legazpi City

_____________________________