Republic of the Philippines

Department of Environment and Natural Resources

ENVIRONMENTAL MANAGEMENT BUREAU
Region VII, Banilad, Mandaue City
Telephone: 3469426 / 3453905 Fax: 3461647

APPLICATION FORM FOR DISCHARGE PERMIT

New 

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: Establishment/PSIC Code: Year Established:

Plant Address: No. & Street Name: Barangay:
City or Municipality: Province:
Type of Industry: Tel. No & Cel. No.:
Name of PCO: Fax:
Accreditation Date: Company E-mail:

Legal Classification: Proprietorship Private Corporation Multinational Other:Specify

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:

Monthly
Sources of Water Supply Ave. Daily Ave. Generating Process Estimated Flow
(Vol. m3) (Vol. m3) (m3/day)
MWSS (please attach water bills) Process Wastewater
Local Water District (please attach Washing/Cleaning of
water bills) Process Equipment
Deep Well Cooling
Surface Water (lake, river, creek, etc.) Domestic
Others Recycled/Reuse
Others (drinking water,
gardening, evaporation,
leaks, product component,
etc.)
Total Water Consumption Total Volume of Discharge
Wastewater

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

Total Floor Area (m2) No. of Bedrooms Number of Guests/year

Total Area for Dwelling Units No. of Restaurants/Dining Units
Product Information
Product 1 Product 2 Product 3
Product Name
Actual Production Capacity
Actual Production in the previous year
Type of Process Batch Batch Batch

Note: ** Please use generic product name, not in brand names, in metric tons of products carbonated drinks and beers(m 3)
except for the following substances: hog raising (heads) slaughtering/preserving

Water Pollution Information

Location & Distribution Estimated Ave. Estimated Ave. Estimated Ave.

Outlet of the Outlet BOD/TSS rate of Discharge BOD/TSS Load
Number Concentration (m3/day) (kg/day)
(mg/L)

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: _____________________ Amount Php: ________________

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 Chief Executive Officer

SUBSCRIBE AND SWORN to before a Notary Public. This _______ day of ________. Affiant
exhibiting to me his/her Community Tax Receipt No. ________ issued.

NOTARY PUBLIC