Republic of the Philippines

DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCES

ENVIRONMENTAL MANAGEMENT BUREAU
Office of the Regional Director
Region IX, Western Mindanao
Lantawan Pasonanca, Zamboanga City
 (062) 985-0428 / 985-0429

Application for Discharge Permit

New X

Renewal Expiry Date TIN

Application No.
INSTRUCTION: Fill in all appropriate white spaces. Mark all appropriate boxes with an “X”.
NOTE: Failure to complete this form may be sufficient ground for disapproval of the permit application.

GENERAL INFORMATION:

Name of Establishment/Plant: Est. Code: Year Est.

Plant Address No. & Street Name Barangay:

City or Municipal: Province:

Type of Industry:

Name of PCO Accreditation Date:

Tel. No. / Cel. No. Fax No.

& Email Address

Legal Classification

Proprietorship Private Corporation Multinational Others: Specify Government

Ownership Terms (%) private % Foreign % Government %

EMPLOYMENT AND OPERATION INFORMATION

Total Employment (number of workers) in the factory: Production Non-Production

Production Time: Number of Hours/day Number of days/month Number of months/year

SOURCES OF WATER SUPPLY AND WASTEWATER GENERATION

Sources of Water Supply Monthly Ave. Daily Ave. Generating Process Estimated flow
Vol. (m3) Vol. (m3) (m3/day)

MWSS (Please attach water bills) Process water

Local Water District (Please attach Washing/Cleaning of Process equipment

Water bills)

Deep Wells Cooling

Surface water(lakes, river,creek, etc.) Domestic

Others Recycled/reused

Others (drinking water, gardening, evaporation

Leaks, product component, etc.)

Total Water Consumption Total Volume of Discharge Wastewater

Dwellings Units Information (hotels, condiminium, restaurants, malls, etc)

Total floor area (m2) No. of bedrooms No of Guest/year

Total Area for dwelling Unit (m2) No of Restaurants/dining unit

PRODUCTION INFORMATION

Product 1 Product 2 Product 3

Product Name

Actual Production

Actual Production in the

Previous Year

Type of Process Batch Batch Batch

Continuous Continuous Continuous

Note: **Please use generic product name, not in brand names, in metric tons of product, carbonated drinks and beer (m3)
except for the following substances: hog raising(heads) slaughtering/preserving

Water Pollution Information

Location & Distribution of the Name of the Receiving Estimated Ave. Estimated Ave. Estimated Average
Outlet body if not Discharging BOD/TSS conc. Rate of Discharge BOD/TSS Load
Outlet In the lake. (mg/l) (m 3/day) (kg/day)
Number
1

Name of Laboratory performing Analysis:

Address of Laboratory:

Date of Sampling : Date of Analysis

Method of Sampling :

Vicinity Map (The map should show relative location of the establishment with respect to existing structures, landmarks, rivers, lakes and
Other water bodies, etc..Use scale to fit into the frame below.

Fixed Fee Official Receipt Number:_____________________ Date of issue__________________

I hereby certify that the above information are true and correct to the best of my knowledge. Done this _________day of_________________
of 20______________.

_________________________________________________ _______________________________________________
Name and Signature of the Pollution Control Officer CEO / MANAGER

SUBSCRIBE AND SWORN to before a Notary Public. This __________ day of ____________________.Affiant exhibiting to me his/her
Community Tax Receipt NO._________________Issued at _______________________ on______________________.

NOTARY PUBLIC
 REQUIREMENTS FOR APPLICATION FOR A WASTEWATER DISCHARGE
PERMIT

FOR NEW APPLICATION

a) Engineer’s Report containing such information as:

i) Vicinity map identifying the street address, location or plant premises;

ii) The nature of project or business;
iii) Production capacity; quantity or volume and the generic name(s) of product(s)
iv) The nature and character of the applicant’s wastewater and its physical and chemical
composition;
v) Total daily volume of discharge of raw wastewater;
vi) Treatment process and estimated treatment efficiency;
vii) The total daily volume of water consumption and discharge of final treated wastewater or
effluent
viii) The name of receiving body of water and its official water classification and in case of land
discharge, the nearest receiving body of water and its official water classification;
ix) Information on flow measurement equipment and procedure;
x) Pollution prevention/Environmental System plan of program;
xi) DENR ID Number as hazardous waste generator (if applicable)
xii) Statement of the cost incurred in the installation and maintenance of wastewater treatment
facility, if any;
xiii) Quality and quantity of abstracted water; and
xiv) Copy of Environmental Compliance Certificate (ECC) from the Department of Certificate
of Non-Coverage (CNC), as applicable.

A registered chemical or sanitary engineer or Pollution Control Officer shall sign such engineer
report concurred by the Managing Head.

FOR RENEWAL OF DISCHARGE PERMITS

b) A copy of the quarterly self-monitoring report for the immediately preceding year.
c) A copy of the Certificate of Accreditation of the Pollution Control Officer duly issued by the
department, or appointment/designation as such by the Managing Head;
d) Official receipt for the payment of the applicable Fixed fee; and
e) Other documents that may be required related to land application

Failure to submit the necessary requirements shall be sufficient ground for

the disapproval of application.