Department of Environment and Natural Resources

Environmental Management Bureau

Reference No:
(to be filled up by DENR only)

GENERAL INFORMATION SHEET

Name of the
La Union Medical Diagnostic Center and Hospital, Inc.
Establishment/Facility
Establishment/Facility Street # & Street Name:
Address
Barangay: 3 City/Municipality: City of San Fernando
(NOT the company of
head office) Province: La Union
Name of
Mr. Jose A. Madayag, Jr.
Owner/Company
Address Street # & Street Name: # 21 Beach Homes Subdivision
(if address is not the
Barangay: Lingsat City/Municipality: City of San Fernando,
same as previous
address) Province: La Union

Phone Number 072-607-8339 / 607-3898 Fax Number

e-mail address launionmed@gmail.com

Philippine Standard Industry Classification Code No. 61

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

Responsible Officer/s:

Name. Mr. Ariel Nisperos

Pollution Control
Tel #: 09126398703 Fax #:
Officer
E-mail address: arielnisperos.lumed@gmail.com

 single proprietorship  partnership

Legal Classification x private domestic corporation  government corporation
 Multi-national 

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

Mr. Jose A. Madayag Jr. Mr. Ariel C. Nisperos____

Name/Signature of President Name/Signature of PCO
Name of Plant:
Reference No:

Department of Environment and Natural Resources

Environmental Management Bureau

1st QUARTER SELF-MONITORING REPORT

MODULE 1: GENERAL INFORMATION

Name of the Plant La Union Medical Diagnostic Center and Hospital
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 WWDP-R01-19-01387
PO No. June 14,2020 June 14,2021
(Pending application)
ECC 1 01 0409-06-0078-0604 Sept. 06, 2004
PD 1586 ECC 2
ECC 3
DENR
M-GR- R1-33-00059 Jan. 18, 2019
Registry ID
CCO
Registry
RA 6969 Importer
Clearance No
Permit to
OL-PTT-R3-69-019651 June 10,2021 Nov 20, 2021
Transport

A/C No.
RA 8749
PO No. POA-181-01LU14-152 Nov. 09, 2018 Sept. 23, 2023

Module 1: General Information page ____ of ____

Name of Plant:
Reference No:

Operation
Operating hours/day Operating days/week # of shift/day
Average 8 7 3
24 7 3

Operation/Production/Capacity:
Average Daily OPD-80pax/day
Total Output this Quarter OPD-7200/ IPD-392
Production Output IPD-4pax/day
Total Water Total Electric
Consumption this 566m3 Consumption this
111,960 kwh
Quarter (cubic meters) Quarter (KwH)
Please use additional sheet/s if necessary

Module 1: General Information page ____ of ____

Name of Plant:
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

For producers
Average Daily
Total Output this Quarter
Production Output

Module 2C: RA 6969 (Hazardous Wastes Treater/Recycler) page ____ of ____

Name of Plant:
Reference No:

Quantity of Stock Quantity of Stock

Inventory (Start of Inventory (End of
Quarter) Quarter)
Name of Buyer Quantity Date of Purchase

Total Quantity Sold

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

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

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:

Manner of handling X storage on-site X Treatment on-site

hazardous wastes  storage off-site X Treatment off-site
Changes in Safety  Yes (please attach copy of revised plan)
Management System  No

Module 2C: RA 6969 (Hazardous Wastes Treater/Recycler) page ____ of ____

Name of Plant:
Reference No:

 Yes (please attach copy if not submitted/included in previous report/s or had been
Chemical Substitute revised)
Plan
x 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
M501 Infectious Solid/liqui Toxic none m.t. 2,900.00 mt
waste d
D407 Mercury and Solid/gas Toxic .004 m.t. .0009 mt
Mercury
compound

Module 2C: RA 6969 (Hazardous Wastes Treater/Recycler) page ____ of ____

Name of Plant:
Reference No:

Waste Storage, Treatment and Disposal:(Please fill-up one table per HW)
HW No,: M501
HW Details Qty of HW Treated: 2,900.00 Unit: metric ton
TSD Location: Tarlac

Name: Infectious waste

Storage
Method: Metallic drum

ID: OL-PTT-R3-69-019651 Name: Cleanway Environmental Mgt. Solutions, Inc.

Transporter
Date: Nov 20, 2021

ID:___________________ Name: ______________________

Treater
Method:______________Date: ___________________

ID: Name:
Disposal
Date: Date:

HW No,:
HW Details Qty of HW Treated: Unit:
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)
Labeled drums of
different kind of waste,
April. 04, 2021 Infectious storage area No labels and weight quantity generated,
disinfected and sealed
drums.
Labeled drums of
different kind of waste,
April 12, 2021 Infectious storage area No labels and weight quantity generated,
disinfected and sealed
drums.
April 18, 2021 Infectious storage area No labels and weight Labeled drums of

Module 2C: RA 6969 (Hazardous Wastes Treater/Recycler) page ____ of ____

Name of Plant:
Reference No:

different kind of waste,

quantity generated,
disinfected and sealed
drums.
Labeled drums of
different kind of waste,
quantity generated,
April 25, 2021 Infectious storage area No labels and weight
disinfected and sealed
drums.
Scrubbed storage area
Labeled drums of
different kind of waste,
May 01, 2021 Infectious storage area No labels and weight quantity generated,
disinfected and sealed
drums.
Labeled drums of
different kind of waste,
quantity generated,
May 11, 2021 Infectious storage area No labels and weight disinfected and sealed
drums.
Washed drums &
cleaned storage area
Labeled drums of
different kind of waste,
quantity generated,
May 19, 2021 Infectious storage area No labels and weight
disinfected and sealed
drums.
Cleaned storage area
Labeled drums of
different kind of waste,
May 29, 2021 Infectious storage area No labels and weight quantity generated,
disinfected and sealed
drums.
Labeled drums of
different kind of waste,
quantity generated,
June 10, 2020 Infectious storage area No labels and weight
disinfected and sealed
drums.
Cleaned storage area
Labeled drums of
different kind of waste,
June12, 2021 Infectious storage area No labels and weight quantity generated,
disinfected and sealed
drums.
Labeled drums of
different kind of waste,
June 17, 2021 Infectious storage area No labels and weight quantity generated,
disinfected and sealed
drums.
Labeled drums of
different kind of waste,
quantity generated,
June 23, 2021 Infectious storage area No labels and weight disinfected and sealed
drums.
Washed drums &
scrubbed storage area.
June 29, 2021 Infectious storage area No labels and weight Labeled drums of

Module 2C: RA 6969 (Hazardous Wastes Treater/Recycler) page ____ of ____

Name of Plant:
Reference No:

different kind of waste,

quantity generated,
disinfected and sealed
drums..

C. Hazardous Wastes Treater/Recycler

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

Type of
Transport Storage Time
HW Wastes Date of
Permit/Date Valid until Quantity Container/ Table for
Number Generator Transport
of Issue # of Treatment
containers
OL-PTT- 4th week of
M501 LUMED R3-69- Nov. 1,900 mt METAL Aug. 2021
019651 20,2021 DRUM / 8
DRUMS
OL-PTT- 4th week of
D407 LUMED R3-69- Nov. .004 mt METAL Aug
019651 20,2021 DRUM / 1 2021
DRUM

Module 2C: RA 6969 (Hazardous Wastes Treater/Recycler) page ____ of ____

Name of Plant:
Reference No:

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

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

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

Type of
Process by
Storage
Type of which the Disposal Time Table
HW Number Quantity Container/
Wastes Wastes is Option for Disposal
# of
Generated
containers

Module 2C: RA 6969 (Hazardous Wastes Treater/Recycler) page ____ of ____

Name of Plant:
Reference No:

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

Water Pollution Data

Domestic wastewater Process wastewater
6.2197 m3/day N/A
(cubic meters/day) (cubic meters/day)
Cooling water Others: ___________
N/A N/A
(cubic meters/day) (cubic meters/day)
Wash water, equipment Wash water, floor
N/A 1.2439 m3/day
(m3/day) (cubic meters/day)

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

Month 1 Month 2 Month 3
Person employed, (# of
1 1 1
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 In front of Hospital ( Municipal Drainage) CLASS D (Inland water)
2
3
4
5

Module 3: P.D. 984 (Water Pollution) page ____ of ____

Name of Plant:
Reference No:

Detailed Report of Wastewater Characteristics for Conventional Pollutants

Outlet No.
Effluent ________
Oil & Temp
Flow BOD TSS (name)
DATE Color pH Grease rise
Rate (mg/L) (mg/L)
(mg/L) (ºC)
(m3/day) (unit)

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

Detailed Report of Wastewater Characteristics for Other Pollutants

Module 3: P.D. 984 (Water Pollution) page ____ of ____

Name of Plant:
Reference No:

Outlet No.
Effluent ________ ________ ________ ________ ________ ________ ________
Flow (name) (name) (name) (name) (name) (name) (name)
DATE
Rate
(m3/day) (unit) (unit) (unit) (unit) (unit) (unit) (unit)

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

Please use additional sheet/s if necessary.

Module 3: P.D. 984 (Water Pollution) page ____ of ____

Name of Plant:
Reference No:

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

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

1.

2.

3.

4.

Quantity # of hrs of
Fuel Burning Equipment Location Fuel Used
Consumed operations
Power House 1 Diesel
176hp Standby Gen-set 107.92 gals 9.5 hrs.

CUMMINS Diesel Engine

3.

4.

5.

6.

Pollution Control Facility Location # of hrs of operations

1.

2.

3.

4.

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

La Union Medical Diagnostic Center and Hospital.

FUEL BURNING STATIONARY SOURCE INSTALLATION
1st Quarter for the year 2020
Operating Data:

Module 4: RA 8749 (Air Pollution) page ____ of ____

Name of Plant:
Reference No:

one(1) unit 176hp CUMMINS diesel engine as prime mover coupled to 220 kva Alternator/Electric
Generator as standby power source

Run Hours----------------------------------------------------------- 9.5 hours

Fuel Consumption (Quarterly)--------------------------------- 408.5 / 3.785 = 107.92gals
Specific Fuel Consumption Liters/KW-hr-------------------- 43 liters/hr.

Emission Estimates Computation

E = Emission Estimate
A = Activity Rate (estimated fuel consumption in liters/quarterly)
EF = Emission Factor
ER = Overall Emission Reduction efficiency %

Emission Factors (E.F.) for diesel engine with rated output less than 600 HP

CO = 131 lbs. per 1000 gallons of fuel burned.

NOX = 607 lbs. per 1000 gallons of fuel burned.
SOX = 40 lbs. per 1000 gallons of fuel burned.
PM = 43 lbs. per 1000 gallons of fuel burned.
VOC = 49 lbs. per 1000 gallons of fuel burned

Since there is no emission control system, therefore: (1-ER/100)=1.0

A. = Carbon Monoxide, CO
E=107.92 gals /quarterly x 131 lbs. / 1000 gals x 1 ton/2210 lbs.= 0.00639706787 ton/qtr.

B. Nitrogen Oxide, NOX

E= 107.92 gals /quarterly x 607 lbs. /1000 gals x 1 ton/2210 lbs.= 0.02964137556 ton/qtr.

C. Particulate Matter, PM
E= 107.92 gals /quarterly x 43 lbs. /1000 gals x 1 ton/2210 lbs. = 0.0020998009 ton/qtr.

D. Sulfur Oxide, SOX

E=107.92 gals /quarterly x 40 lbs. /1000 gals x 1 ton/2210 lbs. x .005%/100% = 0.00195330316
ton/qtr.

E. Volatile Organic Compound, VOC

E= 107.92 gals /quarterly x 49 lbs. /1000 gals x 1 ton/2210 lbs. = 0..00239279638 ton/qtr.

The above computation showed that the resulting emission concentration of air contaminants from the
proper combustion of diesel oil of the generator set is within tolerable standards.

Detailed Report of Air Emission Characteristics

Description/Locatio
n
of PCF
_______ _______ _______ _______
Flow _ _ _ _
CO NOx Particulate
Rate (name) (name) (name) (name)
DATE (mg/Ncm (mg/Ncm s
(Ncm/day
) ) (mg/Ncm)
) (mg/Ncm (mg/Ncm (mg/Ncm (mg/Ncm
) ) ) )

Module 4: RA 8749 (Air Pollution) page ____ of ____

Name of Plant:
Reference No:

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

Please use additional sheet/s if necessary.

Module 4: RA 8749 (Air Pollution) page ____ of ____

Name of Plant:
Reference No:

MODULE 5: P.D. 1586

Ambient Air Quality Monitoring (if required as part of ECC conditions)
Description/Locati
on
of Monitoring
Station
_______ _______ _______ _______
_ _ _ _
Noise CO NOx Particulat
(name) (name) (name) (name)
DATE Level (mg/Nc (mg/Nc es
(dB) m) m) (mg/Ncm)
(mg/Nc (mg/Nc (mg/Nc (mg/Nc
m) m) m) m)

(Please accomplish one table per monitoring station.)

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

Description/Locati
on
of Sampling
Station
_______ _______ _______ _______ _______ _______ _______ _______
_ _ _ _ _ _ _ _
DATE (name) (name) (name) (name) (name) (name) (name) (name)

(unit) (unit) (unit) (unit) (unit) (unit) (unit) (unit)

Module 5: P.D. 1586 (EIS System) page ____ of ____

Name of Plant:
Reference No:

(Please accomplish one table per sampling station.)

Other ECC Conditions
Status of Compliance
ECC Condition/s Actions Taken
Yes No
1.
2.
3.
4.
5.
6.
Please use additional sheet/s if necessary.

Environmental Management Plan/Program

Status of
Enhancement/Mitigation Measures Implementation Actions Taken
Yes No

Module 5: P.D. 1586 (EIS System) page ____ of ____

Name of Plant:
Reference No:

Please use additional sheet/s if necessary.

Solid Waste Characterization/Information:

Average Quantity of Total Quantity of
Solid Wastes .750metric ton Solid Wastes 2.25metric ton
Generated per month Generated this Quarter

Average Quantity of Total Quantity of

Solid Wastes Collected .72metric ton Solid Wastes 2.16metric ton
per month Collected this Quarter
Entity in charge of
LOCAL GOVERNMENT UNIT (municipal garbage truck)
collecting solid wastes

Recyclable items (pet bottles, scrap cartons/papers etc.) are sold to junk
Brief Description of shop.
Solid Waste
Management Plan
(e.g., waste reduction,
segregation, recycling)

Module 5: P.D. 1586 (EIS System) page ____ of ____

Name of Plant:
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 __July 15__ in ______2021________.

Mr. Jose A. Madayag, Jr. Mr. Ariel C. Nisperos_____

Name/Signature of President Name/Signature of PCO

SUBSCRIBED AND SWORN before me, a Notary Public, this ________ day of

______________________, affiants exhibiting to me their Community Tax Receipts:

Name CTR No. Issued at Issued on

Ariel C. Nisperos_______ 02585546 San Fernando, La Union __Nov. 20,2021_

Module 5: P.D. 1586 (EIS System) page ____ of ____