CPD FORM PO-1-2017 ver. 1.

Department of Environment and Natural Resources

ENVIRONMENTAL MANAGEMENT BUREAU
Region VII

APPLICATION FOR “PERMIT TO OPERATE” AIR POLLUTION SOURCE INSTALLATION (APSI)

Type:  New  Renewal  Additional/Replacement  Amendment/Extension
INSTRUCTIONS:
1. Fill-in application form, computerized or handwritten in block letters. Write N/A on blanks which are not applicable.
2. Please provide two (2) sets of copies of the application documents listed in the checklist of requirements.

1. GENERAL INFORMATION
Name of Company/Permittee: ________________________________________________________________________________
Company/Permittee Address: ________________________________________________________________________________
Name of CEO/President/Owner: ______________________________________________________________________________
Office Address:_______________________________ ____________________________________________________________
Telephone/Mobile No.: ____________________________ E-mail Address: _________________________________________
Nature of Business: __________________________________________________ Start Date of Operation: __________________
Nature of Ownership:  Single Proprietorship  Partnership  Corporation
Name of Pollution Control Officer (PCO): ___________________________________ Accreditation No.: ___________________
Tel./Mobile No.: _________________________________ E-mail Address: _________________________________________
ADDITIONAL INFORMATION
Authorized Capital: _________________ Paid Up Capital: ___________________ TIN: _____________________________
Total Employees: ________________ ( Office: ___________ Production: ____________ )
Office Operation: ______hrs/day _____days/wk Production Operation: ______hrs/day _____days/wk
2
Land Area Occupied: _____ m 2
Open Area: _____m  Owned  Lease  Shared
Land Use:  Industrial  Commercial  Residential
Agricultural  Others:____________________
Domestic: ____________
3 Others (_________):
Discharge Permit No.: ___________ Wastewater Generation (m /day):
Process: ______________ _______________
DENR ID as Hazardous Waste Generator: __________________________ Date Issued: _____________________________
ECC/CNC No.:________________________________________________ Date Issued: _____________________________

2. AIR POLLUTION SOURCE INFORMATION

 For renewal application, please check () if the same list of equipment as per previous Permit to Operate (PO).
Rated Rated Material APCD
Fuel Consumption
Name of Equipment/Installation Qty. Fuel Type Capacity Output Capacity Stack Height (m)
(Li/day or kg/day)
(kW or Hp) (kg/hr/eqpt.) (m3/min)

(Please continue on separate sheet, if necessary, using the same format above.)

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

_________________________________________ _________________________________
Signature over Printed Name of the PCO Signature over Printed Name of
CEO/President/Owner/Managing Head
SUBSCRIBE AND SWORN to before a Notary Public this _______ day of _________________________. Affiant
exhibiting to me his/her Community Tax Receipt No. ________ issued.
NOTARY PUBLIC
Banilad, Mandaue City, Cebu, Philippines, 6014
Tel. Nos. (+6332) 3469426,3453905 Telefax No. 3461647
Email: emb_regionseven@yahoo.com.ph