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 3. fvfoOe of Ertraction:

N,[onual Ntechtnical-----.---- ,- i\'trtrrtral & lrlechlnical - i'

Il'Mechanical \Yhat type of Liquiprncnt to bc

trsr-'tl

(please enumerate in the space provide bclow)

(:A PAcl"l'l'/50I Ilt{

tiQUlPi\tuN'l's
(ltentedi 0x rrrd)

PAILLRSnA - I I(J'IITil1)

su,{? fRUCris -2 r.iiiITTD

{. Proof of Owncrchip over the edjaccnt l,end (That is besidc the riycr * here
prcpo*d crlrrction proi cct loceted)

Status of l-nnd OumtrshiP:

tI Owned / title by vlrtuc of

OCT or TCT #-_-
CLT lEmancipation Patent No.
Homestand Patent No.

t1 Owned/untitled (Ta:< I)ecl aration) --

tl Stewardship Contact:--
rI Waive frorn the Rightful orvner signifying pcrrnislion

t ] Others, please specit'y

ACCf,SSIBTLITY TO I'IIE SI'I'E

(Mrlde#rotrtes)
t
.l

Barangay
Road: sat{ vIcIilIl'}J
ProvinciaHNational
Highwoy: sdll HtlruirJ
Priva.te
Road IIN PRTUATE T?NA,T) TO Bf USED.

6r{8.JJFTIC'AL FiLT

;. .Fi-B$

v \
 I)l y'.rrr ir;r',i.
j'll: \t (.'l')r.!1, :tltl

l'..11\(l:l lt51i(' l,l.'l lrrl i:,r

,tr. iii'.,1 lri,:il ' r,l' 'ti

3.il srde ','ii'

a- {:t.a

. ..." .,r !

i.i
i:r
\\'cst side vi(.r\

gls-0FFtc,AL
rot
0.--f
s7
 .ir

t.

.rfili sirle I'iew

Scluth side view

.4I
'i

SlEt-oFF1C;AL HLE

F-h*, i..

vil
 \/

C" DESCRIP'I'TON OF E.\IS'TING

(Rcnrarks: To be lirerJ-up
ENVIIT,iiII,!:I,J I'
rh"l\;;r;.i,, unrt I)r,\rt- pur.,.r,n-.r *,hr
evaluation/ocular inspe.tio,, tv,lli q'rl;r..,., : ,l;g.;t
uf tf:J rii"i'

CCI}TPONE NITIIAR,T]}TF.'
l'ERS
*
t
.-+
--t-- It c.1r,t !t;i.\
^il I

Proponent trt: \ tr
PFIYSIC;\L f NVI RONI!{ENT I
I
What is tl:e general cvaluation I
of rhe project I
area
< I0O masl vl
^l / Belor ZA 'te t
I0G300 masl
301-500 masl I

501-1,000 nrasl I /
I
I
(to be deernrine evaluation, I I
refer ro thc I
topographic *h.re- I
llpindicated)rhe erul-ruri J' p*,
contour line is
i I
I
I
I

,
I
Slope and topographic I
I
of the river bank I

I'errain is flat or lel I

x fla,t
s;;H,H,,'ffiIll,i'ifryi' I
I
I

the adjacent with Ikm. I

flop.of
from Radius
the Erea:
I
Fhst ward
lVcst ward
x
x
roEtlvely I I
South lyard -Oo-
x I
North ward rela tlye Iv w
-L
9
c.) Estimate volun
dil,u-;il;*ilf it iflesate s Presen t
-do- t,
Bqrlders:
,l
I, .,
Fine Sand: no bouldorei
I
Gravel: x eufflcient I
,,1
x eufflclent I i

I
I

ffiffiiTl,#n.fl*',ffir' no f]ash .fl !t

do
I
.1
I

i
I
l
J
-&%._

**Y

Ytg
What kind of acccss road will trc
tt 3t'erscd:
cemcnted j[,ra\ c;icrl
clirt road as[)haltcd
__L
others

Whatafethepreseltttrsesol.thewaterborlicsrvithin()rneariheextrecttcrn
\'l'atc'
bathing / *washing -'L-- - -'-*--source ol'dninking
""ring-
others

area?
What is the prescnt land use of the surrounCing

Prime Agricultural Land (productive

& irrigated)
- prime'Agricuttural Lanrl (iclle/abandoned)
il;;;r
t-Aarshland/ lr{angrove
- please spec ify _-___
- '-
Area --others' -+
-:ivatershed
within I kilometer radius lianl proposed
existing permittec(s) extractor(s )
-ffitffi
Are thcre enY
ait pernriues
sr&re narnc crf
i:.J No_l*_ If yes how nuny _=._=_(please
;-rA, l'steetffistiiltd volume ofextraction/trectare

BIOIT.}GICAL ENVIITON MEN-N' REIll,'r [iIiS

Y F{
COIITFONEN'ITPATTA' &t ETET{S i

Proponent Iitif{R

Are thc existing trees and other types of none

vegetataion in the site and surrounding
within 100 meters radius.

Are there birds and other I'oi-ms of wildlile uouc

found in the area?

Are thcre fishing resotlrr.es in the

waterbodics found neaf, or r.,,ithin the nor-r0
er(traction site?

Is the site ncar or within a watcrshed or

forest reservation area? nono
lf pe8r,llow near? Poo" .*il:etcrs I
t
I

If withig indicate name of the watershcd or I

I
forest reservation" -J

If enswer k'YES" to the el rvs questious, plense providc erarrples of tlle rPsier:

,. -*-**,. i f_J
qv
 JJtr---

'ft'ccs and 0tlrer I'ishery fle .'t tt r cr

Ilirds nntl Othet"s
Lrt Vc g t t :r t i o rt-
Wildlife _EUt-t-f.t lr

.:fii.5 se Ii Luca} i;:l''

lbla;trb var i'. t !- i. ll --:; i' " r.'

iisr, uguar Iy iivtng I

l
l
i
t-
riv,:r'.
in tire rlver. I
t-
I
I

--1
I
t-,

3. SOCTG'ECONOMIC

Y N RS:MA I{TiS
COftTPONE N T/PAR,,{l'rt}l'fn R^S

Propcne;;t u ui\i R
t
-{
Are tlrcrr ercisting settlernents is near the sitc
(at least than I km. Radius.

/No rlonc
Yes
If 'L85" How manY I{ouscholds?

WhEt are the source.{s) of income: Farn"ing

Livelihood TPe: Alrlloal iBIs

ken t
pou I It ralel t

I
t

-l_
:

Ane thcrc cristing sociel infiaslruclure? Please Ch cclt.

Churches/ ChuPel Itre:rith Clin i#(-'cn t* ru
Bni$p,cr ilals .; l. ,,
-l--School Flease spccify

EN+BF 8trffiD}Al FILF

''\. . F*_, f-*..-*t

{b
 5 t i,"-t'
vtllt ;,/l Qllt a

ild vl':t r r'lt.l

/ /<t ,/,t'.'

! r.;

,6
c?N^{Po t'h)flLi/t\

EMB. ilFFICIAL FILT

*-l
t

K
 - rhe n{:liauvi i:r tic Yr I'i cr;lrrn'rr )

lil,llfJ,f;1iilitr;*l,lJiTJJ:l;11'll.r
oi' d?e S"lG prtrytct'
l'{ote: No pre<rnstruction period
N C:
CS AT'FEC'I'I
PROJECI. AC'TIVITI It itiertion"
lnrPnct Iinhe.icenltst
N{ENT
l' r.i
[]escriPtion !\learurc t
PilYSICAL E,NV IRON

I. I,A'ND
result in:
Wiff G ProPosal
excavation or
a. ComPactior; covering,
iirit beYond/ in site
disPlacement "rir,t
conditions?

b
ffi:::ll$ffi[:r#],1!li^:-
ntt* nalural surounding
inconsistent'*"ii
conditions?
c. il"*Uf" earth conditions?
geologic
d. Churge in the soil or
i srb*nrcnrres?

or increasc in wind
e. The continuation of
*"on'#'oilt' tittttr on or olT
or wder
the site?

or erosion of
Changes in disposition
f.
o:,tll
#;:;a orh ero$o l,li' 113,,,,
.

deDosition
iififfi;ioru tiuti or slream or bed of
a lakc?
.f

?,. ALR
resr'rlt in:
-litth Project
Will
li"i pollution ernissions or
" Jaerio*tion of ambient rir?

EU?r.} 'Qr'-tc}}) T F

.-\ :
' f--+

4/ \
 't.

,
I lll itigation/
Impact
PllYstcA L EN VI tlON ilt rlN'r Y N I Flohancerneul
Description I
.!learurc:t
t.

3. 1VATER
I

t
I

a Charges in currerit, c{ the cours('or I

direction r.'rf wa ter rnrrvemeilt? I

I

b. Alternative to the course of l]ow or 100- Y

year flood waters?

c" Discharge into any surface water body

pollutants that could &lter urater quality?

d. Alteration of the direction or rate of florv

waters?

e. Change in the quality of watcrs through

interoeption of an aquifer by cuts or
o<cavation?

f Substantial reduction in the amount in

the aruount nf water othenrise availablc
for public wate.r supplies?

4, PI"ANTLIFE I

I
Will tho proposal result in: I
I
!. Rernoval of any vegetative cover or
other vegaatiorr associsted with criticat I
I
I
I
wildlifs lrabirat? I I
I t I
b. Changes in the diversity of species, or of i
I
any species, of plants (including trees,
I
shrub* grass, crops, microflora and .t I
I
aqusth plants? I

I
Rductioo of the nurnber of any uniquq rare
or qlengcred species of plants?
I
J

.'tE
Etis- 0FFlClAu
t

t
l
g t' rt,

13
 I

-t T- llitrqetior:/
lrnlr*ct I
t"r:hlncernent
PII}'SICA I, EIi 1/I RON }T EN'I' I li
Description I
t
I lleacurcr
t

5. ANIIT{Al, t,ll,'E
t

a. Change in thc divcrsity ol'spccics or

numbers of any species of aninrals i

(birds, land, animals including reptiles, I

fish and shellfish benthos organisms,

insects or micro fauna)?

b. Reduction of the number of any unique,

rare or endangered species of animals?

c. Deterioration of existing fish or wildlife

habitat?

6. SOCIO.ECONOMIC

a. lncrease existing noise levels?

b. Exponre of people or property of

geologic hazards such as earthqualtcs,
landslides, mudslides, ground failure, or
similar hazards?

1. TRANSPORTA.TION/
CICUI.ATION

Witl the proposalresrlt in:

& Substantial impact upon existing ,{

' transportatioosystem. I
.l

b. Ahcrations to watcrbone, rail or &ir

traffic?

c. Imrcasc in traffic hazards to motcr t

vehicles bicyclists, or @estrians? I

t

FILT
EMB- OFFICIAL

:. ,.. *.-*, 0- __J

{a
 'r

r--'- I
i I
Inrpacl
I
Stitigation/
PIIYSTCA- L EN VIII.ONIIT If{'I' il' I

I
Ilrscriirtion
i
l Sln!rancemeut
I
I I jtlcasures
S. PTJBLT{:] SERVICil$
a
I
Will the proposal have an unplannerl r,lJecr I
I
!.rpon, or rss!.rlt in a need for nerv or altcrcd
govenmtc,ttal services in a;ry cf the I

following {rcas:

a. Fire prot*ction?
b. Police protection?
c. Schools
d. Par&s or other recrealiornl facilities?
e. Msintenance of public facilities, ropor;,ent s
inch,rding roads? x lur:dertake ro
f Otfier Sovennmental scrvices? grBYeIl1n6.

9. ARCIIEOI,OGICAI,/ fi ISTORICAL
Will thc proposal result in an alteration of a
*ignificent archeological or historical sire,
stru*ure object, or building?

IO. RIANi}ATORY ITINDTI}iGS OF

SIGI+{IF't'ANCE

& |ocs th€ projcct have the poteutial to

degadethe quatit.y of the enrironment,
flrbstantislly reduce the habitat of a
{rsh
population to drop betow self-sustaining
levels, threaten to etiminate a plant
or
anirral courmunity, reduce tfr" nunrfo
or restrict the range of a rere or
enda*gered plant or anirnal or
clir.,rinate
rmpr,ortant examnles ofthe
major periods
ttre phitippine rslanas rriffi'#;;.-
3f r{
history?
,I

{&d**-r;' *li 11

6r.{i'{ '0FF}fl!-StI

\
,ll
 *-
lun---

Inrpact i $titigation/
PHYSICA L EN VI ITCIIY}I f, ]\1" Y l1 Hnhrncement
Ilescription
llersures
t. f)oes the projcct have potential to
-.i

I
-l
achieve short tenrq ro the disadvantage I
I
I
I

of long term. cnvironmentalgoals? (a

short+enn impact of the environmcnt is
I
one that occurs in a relatively briefi,
definitive period of time, while long-
term impacts will endure well into the
future).

c. Does the project have impacts that are

individuslly Iirnited, but curnulatively
!
considerable? (A project may impact on
i
two or rnore separate resources is I

relativc smdl, but where the effect of thc

total of those impacts on the
eayironnrent is significant).

d. Does the project have environmcntal

effect that will cause substantial adversc,
effectr on human beings, either directlly
ot'

PROFON r:NTS COMBIITITIENII'S:

Are you committing yourself to... Y N
l. Comply with existing environn:enta! rut cs and regulations, guide! ines and
critsia?

2. comply with all mitigation and enhancement measures that have

becn
identilied in these reports?
{
I

3' U.nderta&e suppfe.meltat planting of trees, bamboos, vetiver grass

rbove to prevent bar* erosion. - or any of the
/
4. Participue or support muiri-partite monitoring
efforts.

5 P,rt-up cstrbfu hed Environm entalMoniroring

Fund of p for the
nsc of multi-partite teem.

6.

.e,.__.
ErtS - 0F F llllAr- riuL,
"\
r-t
,fi
tt::L.
 1r
dt-{

I). A
fitle of Prrt s ctreck &X*rk

l. Ars Cleuanc€ frorn Provincial Mining

Regularory Board (PMRB)
I

.t
2. Vicinity Map I
I

3. Location Map I
I

I
4. Topographic tv{ap J I

i
5. L,GU Resolution (for social acceptability)

6. Photo copy of TCT/OCTICLT, etc. and

or

7. Waivcr of Right for Road-Right of Way

t. PEI{RO/CENRO Endorsernenr /

H[E- ItrGIt'JSL FlLr

t

,
!"."\

Ith-rru
L-.t
',,'..'

w #
I

rll i\ I
'l'irir is lo rcrlifv tlurl':ril tirr inli;:'!rr:rlirlr .r!:(; (;r;rrr:, j1,1;,., 1,1. ir'
"i'i, lri ii
l;.tttil'ttr!nlertlNl l'rarrr;rr:rti(rrr ill l ) ll.,'irort ,tr. l:'.r('..).r,,r,il(, :r:r,l r.r,rrr,: l;,r.-
It'c h'ilrtt cf tnt inf'rrltr:liittfl rrLhi< !. rrould rrf l.r.f :,i,i i1'1.. i."r:.'ri.rrr,,,if. 1i.., 1. r' .,ir
irli{::l.,irlit} illl"il:'r!t:l;i(iu lql iilt. trilcl:irrrrr fil!i}tr},,ri:il; iri.\ilr t11..:.,,. rlrl f}!lu.r.

$'r. itr^rtl,.l liirrrt otrr.,,r.lr r,:".i, ir .l:rrl:., . irr;trr.r iitn. tlv lh,, l r I

inlllrlsr'(l :rri.ritigi , r'otrr anl tnirr r,rlr , l irl :(rlr .,t . lrl .,1:rli. iir)tf1.:r.rl ii,,
in thi:r ll"l'l re1r"rr.

Ilr rvilrtrss rr lrr.mcf, l.'rl r,

ilt

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't"c,Lo
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f' r'xlraq' 1,,

?s
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{ll r!

d ncl n*rvlrd:irrr *r; i :li lh r

i t.' hc,'rhe rct,r'(.r! t r5.

iurlill thc p;rg* )n$ r t,.,.:rrr

,'il,rnrirrnial litrr,:n r:11ii!; ,',rl

l, rr. N,r.
I ;r;1e iio.
ilook No
Srrirs of

oFFlr.laL Fil-E

f--

37