Republic of the Philippines

Department of Environment and Natural Resources

Mines and Geoscience Bureau - Region 1
Provincial Mining Regulatory Board
Province of Ilocos Norte

AREA VERIFICATION REPORT

Applicant’s Information:
Project Proponent ________________________________________________________
Address ________________________________________________________
Contact Number/s ________________________________________________________

Project Details
Type of Application Commercial Sand & Gravel (CSAG) Permit Quarry Permit
Industrial Sand & Gravel (ISAG) Permit

Status of Application New Renewal

Status of Operation Commercial Operation No Commercial Operation
Location : ___________________________________________________________________
Name of River : _______________________________ Area Coverage : ________________

Description of Area and Vicinities

Current Land Use Residential Industrial
Commercial Others: ________________
Agricultural/ Pasture Land
Existing Vegetation Grass and Shrubs Crops
Trees Others: _______________
Slope Flat/ Level (0-3%) Steep (> 18%)
Gently Sloping to rolling (4-18%)

Method of Extraction Systematic Quarrying Unsystematic Quarrying

Others: ______________________________________________
___________________________________________________
___________________________________________________
Public/ Private Works None Irrigation Dam (_________________)
And structures Bridge (______________) Dike (_________________)
(within 1 Km) Transmission Tower (_________________)
Others: ________________________________________________
Estimated Volume: ___________________________________________________________

Survey Latitude ______________________

Longitude ______________________
Description of Corners and Field References
Access Road Trees Others: ____________________________
Taxes and Permits:
Excise Tax CY ____________ Php__________________
Income Tax CY ____________ Php__________________
Mayors Permit No. ___________________ CY____________ Php __________________
Others: _________________________________________________________________
_________________________________________________________________
Commitment
SDMP Yes No _______________________________
_______________________________

Environmental Protection Yes No _______________________________

_______________________________
 Complaints:
Complaints/ Opposition over the area Yes No
Conclusion:
Conformity of present quarry area to the submitted survey plan Yes No
Sufficiency of Alluvial deposit to support operation Yes No
Presence of Public/Private Works/ Structures within 1 km radius Yes No

Recommendation
Application is favorably endorsed Yes No
Remarks: __________________________________________________________________
____________________________________________________________________________

Verified by:

Name: ______Christopher John V. Orteza_____ Name: _________________________________

Designation: ______Engineer II______________ Designation: ____________________________

Name: _________________________________ Verified in the Presence of

Designation: ____________________________ Name: _________________________________

Designation: ____________________________

Name: _________________________________ Verification Fee: _________________________

Designation: ____________________________

Date Verified: ___________________________

Date Paid: ______________________________

Official Receipt No.: ______________________