|, Name of Plant MABAMA DOCTOR'S HOSPITAL. POBLACION DOS, BANASALAN, DAVAO DEL SUR Reference No: MABAMA DOCTOR'S HOSPITAL Pob. Dos, Bansalan, Davao del Sur October 5, 2021 DR. SOPHIE T. MANUEL, CESO V REGIONAL DIRECTOR ENVIRONMENTAL MANAGEMENT BUREAU (EMB) DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCES (DENR) REGION XI Davao City Madam : Ploase acknowledge receint Please acknowledge receipt the 3" Quarter of 2021. Always anticipating your kind understanding and approval. Very truly yours, Module 1: General Information "page ofName of Plant: MABAMA DOCTOR'S HOSPITAL POBLACION DOS, BANASALAN, DAVAO DEL SUR Reference No: GENERAL INFORMATION SHEET ___3 QUARTER OF 2021 Name of the Establishmen¥/Facilty MABAMA DOCTOR'S HOSPITAL EstablishmentFacilty Address Street # & Street Name: HIGHWAY Ares ay otnens | Ba"2ngay.POB.DOS City/Municipaliy: BANSALAN fea) | Province: ___ DAVAO DEL SUR Name oF Dare Company __| WILLIAM LOWELL CHING-BRAGAT Street # & Street Name: HIGHWAY, Address (addres is notine same | Barangay: __POB.DOS __ CityiMunicipality: _BANSALAN ss reviews *88@58) | royince: __DAVAO DEL SUR Phone Number NONE Fax Number NONE e-mail address NIA Philippine Standard Industry Classification Code No. 86124 ‘Type of Business! Industry | Classification Philippine Standard Industry Descriptor:_PRIVATE MEDICAL HOSPITAL | CEO/President. HIN¢ T Responsible Tel#: NONE. Fax #: NONE Mobile # 0826-8598822 e-mail address: N/A | Officer's: Plant Manager: WILLIAM LOWELL CHING-BRAGAT Tel #: NONE Fax # NONE Mobile # 0925-8538822 e-mail address: N/A Name WILLIAM LOWELL CHING-BRAGAT Fenton Coniol Tel#: NONE Fax# NONE Mobile # 0925-9538822 e-mail address: NONE Legal Classification XJ single proprietorship Cl partnership 11 private domestic corporation 1 government corporation D Multinational o Module 1: General Information page of__ Name of Plant! MABAMA DOCTOR'S HOSPITAL POBLACION DOS, BANASALAN, DAVAO DEL SUR Reference No: Department of Environment and Natural Resources Environmental Management Bureau QUARTERLY SELF-MONITORING REPORT MODULE 1: 3° QUARTER OF 2021 GENERAL INFORMATION Name of the Plant MABAMA DOCTOR'S HOSPITAL. Please provide the necessary revised, corrected or updated information not contained in your General Information Sheet NIA (use adational sheets ¥ necessary) DENR Permits/LicensesiClearances Environmental eo Permits Date of Issue | Expiry Date ‘AIC No NA NA NA P.D. 984 PO No. 2020-W0P-1-1124-2437 _| 1-9-2020 9-24-2025 ect ECC-R11-0811-215-1586 | NOV. 14,2008 | NIA PD 1586 Foc NA NA NA [ecos NA NA NA DENR (On process: | Registry 10 WA RA6960 | CCO Registry NA NA (HOSPITAL) [Importer | rear uo | NA NA NA [Permitto [Femtte [wa NA NA RA 8749 ‘AIC No. NA NA NA (GENSET) PO No. 2019-POA-1124.2437 | 3-5-2019 9-24-2023 Module 1: General information page ofName of Plant: MABAMA DOCTOR'S HOSPITAL N , POBLACION DOS, BANASALAN, DAVAO DEL SUR Reference No: Le Operation Operating hours/day | Operating daysiweek # of shiftiday Average 24 hsiday 7 daysiweek 3 ‘Maximum 24 hrs/day 7 daysiweek 3 Operation/Production/Capacity: ‘Average Daily NA Total Output this NA Production Output Quarter “Total Water Total Electric ‘Consumption this 315 cum, Consumption this. 289 KWH ‘Quarter (cubic meters) Quarter (KwH) ‘Please use adational sets # necessary Module 4: General information__ Name of Plant: MABAMA DOCTOR'S HOSPITAL POBLACION DOS, BANASALAN, DAVAO DEL SUR Reference Nes B. Hazardous Wastes Generator HW Generation: _ T Remaining HW om | tay Ge HwNo, | HWCless | HWNature | 9_.{h¥ | —Prevous Report 1 GS | Quantity | Unit | Quantity | Unit M501 | Miscellaneous | Infectious | Solid na nla none | nla Wastes Wastes PLACENTA | (septic 0 nla vault) - ‘sharps (septic 1 kg vault) Waste Storage, Treatment and Disposal:(Piessefilup one table per HW) HW No, M501 HN Detals Qty of HW Treated: 15 Unit kg TSD Location: Hospital Area Name: Septic Vault Storage Method: Concrete wicover __ ID; a Name: fa Transporter Date not applicable ID: N/A Name: Treater - Method: none_ Date_n/a fla Collection _ Disposal 1 na = Name: illection _ __ none HW Details Qty of HW Treated: none Unit: none TSD Location: none Storage Name nla Method: Transporter 1 te a Treater Disposal ID: nla Name: _n/a__ Date: nla On-Site Self| Inepection of Storage Area: Date Conducted | ea na na Module 2G: RA 6969 (Hazardous Wastes Treater/Recycler)Name of Plant: MABAMA DOCTOR'S HOSPITAL, POBLACION DOS, BANASALAN, DAVAO DEL SUR Reference No: tL MODULE 2: RA 6969 A. CCO Report (please accomplish this section for each chemical/substance) Common Name/IUPACICAS Index Name. CAS No Trade Name: For importers only F cuantty | I] pateor | auantiy | ator | Country of egestas | aC | Ral | Recowetr | envy Monutacre NA Total Quantity a Total Quantity Requested (annual) | Received (annual) + attach copy/s of Bil of Lading For distributors (importers/non-importers) Name of Client Ucense No. Quantity Date of Distribution 1 NA 7 | | ws f + — [ _ Total Quantity Distributed For non-importer users: - { Name of Distributor 1 Quantity | __ Date of Purchase NIA Total Quantity Purchased from Distributor Module 2A: RA 6969 (CCO Report) page of ____ Name of Plant: MABAMA DOCTOR'S HOSPITAL POBLACION DOS, BANASALAN, DAVAO DEL SUR retersnice No: C. Hazardous Wastes Treater/Recycler HW Stored and/or Untreated as of End of Quarter: _ a , Type of Transport Storage tw | wastes | _Date of \ wt La Tanaper | Pemtete | Vols wt | Quanity | Container containers na Wa va nla nla na va HW Treated and/or Recycled as of End of Quarter: Type of | Typo Transport Treatment | Quanity of typeof | HW | Wastes | Date of . Wastes | Number | Generator | Transpot | PermiuDate | Quanity | | or | Recycled IL Process _| “Product L Process by | Storage Type of which the | Disposal | Time Table We tw number | Wastes, | verity | contain | “Seton! | tor peal dooce containers = Module 20: RA 6969 (Hazardous Wastes Treater/Recycler)__ Name of Plant: MABAMA DOCTOR'S HOSPITAL POBLACION DOS, BANASALAN, DAVAO DEL SUR. Reference No: MODULE 3: P.D. 984 (Water Pollution) Water Pollution Data - (ane neanenh 1.62 cu. miday (cme meneien NA (cue metersiday | NA (cube maiortdagy —_| NA Waste [a Misa fat [cam Record of Cost of Treatment (Separate entries for separate facilities) Month 4 Month 2 Month 3 Person employed, (@ cof employees) 1 Person employed, (cost) 396, 00/DAY 308. 00/DAY 396, 00/DAY Cost of Chemicals used by WTP NA NA NA Utility Costs of WTP (electricity & water) 108 KWH. 95 KWH 86 KWH ‘Administrative and Overhead Costs LABORER Same Cost of operating in- house laboratory NA NA NA New/Additional Investments in WTP (Description) NA NA NA Cost of NewiAdd Investments NA NA NA WIP Discharge Location ‘Outlet Number Location of the Outlet Name of Receiving Water Body 1 Hospital Area Primary Conorete Septic Tank alalolny Module 3: P.D. 984 (Water Pollution)__ Name of Plant: MABAMA DOCTOR'S HOSPITAL POBLACION DOS, BANASALAN, DAVAO DEL SUR. Rreterenios No: Detailed Report of Wastewater Characteristics for Conventional Pollutants Please fill uplaccomplish separate formis for other outlets. Detailed Report of Wastewater Characteristics for Other Pollutants Outlet No. | Effluent pate | few anes | iam | Tiaray | wane | “rane | amar |__| (attday)_ | ca | Ta | Te | a | | - NO OUTLET NO DISCHARGE TO ‘ANY BODY L | Pioase i-aplaccemplih soparato tonne Yr other out Module 3: P.D. 984 (Water Pollution) page ___of__ Name of Plant: MABAMA DOCTOR'S HOSPITAL POBLACION DOS, BANASALAN, DAVAO DEL SUR Reference Nor MODULE 4: R.A. 8749 (Air Pollution) ‘Summary of APSEJAPCF _ Process Equipment Location # of hrs of operations 1. NA NA NA 2 3 4 Fuel Burning Quantity | # of hrs of Equipment Location Consumed | operations | 1.GENERATOR SET | HOSPITAL AREA (staNDEY) | HOSPITAL 100 LITERS. | 24 HOURS 2 3 + = 5 § | Pollution Control Faeity # of hrs of operations 1. NA NA NA Cost of Treatment - Month 1 | Month 2 Month 3 | Cost of Person a _ empioyed (say) ne | wa na fotal Consumption | Water cubic meters) _| V@ [ns os Total Cost of chemicals | used (eg., activated | n/a |e va ‘carbon, KMnOs) Total Consumption of Electricity (Kw) me | ve ne ‘Administrative and T Overhead Costs ne jo nla Cast of operating in- house laboratory, if any | 2 [va ive Improvement or [wa ‘la ee | (Description) na Cost of improvement of | n/a Tala nla Lmodification _ _ 1 Module 4: RA 6749 (Air Pollution)Name of Plant: MABAMA DOCTOR'S HOSPITAL, POBLACION DOS, BANASALAN, DAVAO DEL SUR Detailed Report of Air Emission Characteristics Desctiption/Location |___ of pcr FiowRate| co | NOx | Particulates DATE | (bemiday) | (mg/Ncm) 1 a | ee |e |e {mame | m@NI) | ngncm) | (mgr | (gem | (mgm) va va na na wa na na na Please fillapfaccomplish separate formi for other PCF Please use additional sheetis if necessary. Module 4: RA 6749 (Air Pollution)Name of Plant: MABAMA DOCTOR'S HOSPITAL. POBLACION DOS, BANASALAN, DAVAO DEL SUR MODULE 5: P.D. 1586 Reference No: Ambient Air Quality Monitoring (if required as part of ECC conditions) ‘Descrption/Location of Montorng Staton | pate |, Noise | co NOs | Particulates |e Level iom (gir | (8) | (gate | (mgr) | emaINE) | canton | (mgiNom) | (mg/Nom) | (mg wa | na nla nla nia na na na | nla L | ] a | ‘Please accomplichne table per monitoring station) Ambient Water Quality Monitoring (if required as part of ECC conditions) _-Aeabient Water Sealy Monitor cf Sampling Station pang [OT | HRT | TT | aT | ToS | aT | RAT | aT | Tait at | ad | a or) oar ca | na na nla na na na na na na — {-— | lease accomplish one table per sampling station ) Module 5: P.D. 1586 (EIS System)___ Name of Piant: MABAMA DOCTOR'S HOSPITAL —— POBLACION DOS, BANASALAN, DAVAO DEL SUR Retersnce' Ho: Other ECC Conditions . - Status of Compliance ECC Condition’s T ns Taken Yes No Establish appropriate measures and buffer | zones along the entire periphery of the project | / Partial site 2.The hospital operations shall conform with 7 the provisions of government environmental ¥ deat regulations and their implementing Rules and sone Regulations. 3 Environmental Management Plan/Program 3 Status of | 7 | __EnhancementiMitigation Measures implementation Actions Taken Yes No it. Participate the 1 environmental activity. j2tree planting i done . | Please use additional sheets if necessary. Solid Waste Characterization/Information: Average Quantity of | Total Quantity of Solid | | Solid Wastes va Wastes Generated this | nia Generated per month Quarter - | ‘Average Quanity of | | Total Quantiy of Sod | Seki Ween Clcted | 33S hy (recites, | Wastes Cald tie | 4, hg dectioe per month Waste) | Quarter _| Westes | | min Entity in charge of |. | Laborer/COMPANY EMPLOYED = | collecting solid wastes j | | 1 | Brief Description of | Infectious waste is taken out from Garbage Bins. And put it to the | | Sot Weste | Concrete sept vut \ | Management Pian | | | (eg. waste reduction | segregation, recycling) | L 1 Module 5: P.D 1586 (EIS System) - page _of _Procedural and Reference Manual for DAO 2003-27 MODULE 6: OTHERS Accidents & Emergency Records f 1 an — | Bate | Areartecaton | Findings and | Actions Taken | Remarks | | | | | | | | | i \ | | [ nwa | wa Ltwa | wa NA | none none | none | I hereby cortfy that the above information aro true and correct. Done this 06 OCT 2021 in icos city. 6 OCT SUBSCRIBED AND SWORN before’ a Notary Public, this OCT ey of __. affiants exhibiting te community Tax Receipts Name CTR No. Issued at WILLIAM LOWELL CHING-BRAGAT T.1LN. #.919-163-590-000 29a ATTY. JH 200. NO.— pyrene AGE No.. Bren SOK NO. meurMOLlIN RIES SOLL GF ATTO2MEY'S WO, 36063 TIN: (36 -512-317 ‘mene ary Preparation and Submission of SMR 14