Republic of the Philippines

Department of Environment and Natural Resources

ENVIRONMENTAL MANAGEMENT BUREAU
Regional Office No. V
Regional Center Site, Rawis, Legazpi City

APPLICATION FORM FOR WASTEWATER DISCHARGE PERMIT

New 
Renewal  Expiry Date January 27, 2022 TIN 9231-43876000

Application No.

INSTRUCTION: Fill in all appropriate white spaces. Mark all appropriate boxes with an “x”
Note: Failure to complete this may be sufficient ground for disapproval of the permit application.

General Information:

Name of Establishment/Plant ZAPANTA GENERAL HOSPITAL Est. Code 86, 87 Year Est. 1991

Plant Address # & Street Name RIZAL ST. Barangay BANAWAN

City or Municipality PIODURAN Province ALBAY

Type of Industry HOSPITAL

Name of Pollution Control Officer HAZEL B. ZAPANTA Accreditation Date EMB R5AL-N-2020L-3104

Tel # & Cel # 09166049633 Fax #

Legal Classification Proprietorship  Private Corporation  Multinational  Others: Specify

Ownership Terms (%) Private 100 % Foreign % Government %

Employment and Operation Information

Total Employment (number of workers) Production 12 Non-Production

Production Time No. of hrs/day 8 No. of days/month 30 No. of months/year 12

Sources of Water Supply and Wastewater Generation

Sources of Water Supply Monthly Ave. Vol. (m3) Daily Ave. Vol. (m3) Generating Process Estimated Flow (m3)
MWSS Process Wastewater
(please attach water bills) 0.0 0.0 0.0

Local Water District 0.0 Washing/Cleaning of Process Equipment

0.0
(please attach water bills)
0.0

Deep Well 105.0 3.5 Cooling 0.0

Surface Water (lake, river, Domestic
creek, etc.) 0.0 0.0 0.0

Others 0.0 0.0 Recycled/Reuse 3.5

Others (drinking water, gardening, leaks,
product component, etc.) 2.5

Total Water Consumption 105.0 3.5 Total Volume of Discharge Wastewater 0.0

Dwelling Units Information (hotels, condominium, restaurants, malls, etc.)

Total Floor Area (m2) NONE No. of Bedrooms NONE No. of Guest/year NONE

Total Area for Dwelling Unit NONE No. of Restaurants/Dining Unit NONE

Telephone Nos. : (052) 472-2797

: (052) 742-2824
E-mail : mis_emb_r5@yahoo.com & www.emb.gov.ph
Product Information
Product 1 Product 2 Product 3
Product Name

Actual Production Capacity

Actual Production in the previous year

Type of Process Batch  Continuous  Batch  Continuous  Batch  Continuous 

Note: ** Please use generic product name, not in brand names, in metric tons of products except for the following substances: hog raising (heads),
carbonated drinks and beers (m3), slaughtering/preserving meat (ton LWK, electroplating (m2)

Water Pollution Information

Outlet Location and Distribution of Number of the Receiving Estimated Average Estimated Average Estimated Average
Number the Outlet Body if NOT Discharging BOD/TSS Rate of Discharge BOD/TSS Load
Directly in the Lake Concentration (mg/l) (m3/day) (kg/day)
1 N/A NONE 7.34 35.0 0.0
2
3
Total 7.34 35.0 0.0

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

I hereby certify that the above information are true and correct to the best of my knowledge. Done this ____ day of __________ of 20 ___

HAZEL B. ZAPANTA NELLY R. ZAPANTA

Name and Signature of the Pollution Control Officer Chief Executive Officer
(Name, Signature and Position)

SUBSCRIBED AND SWORN to me before a Notary Public. This ___ day of __________ , affiant exhibiting to me his/her Community Tax Receipt No.
______________ issued at _________________________ on _______________________ .

NOTARY PUBLIC