PCO-Form 03

ESTABLISHMENT CATEGORIZATION CHECKLIST FORM

FOR PCO ACCREDITATION

1) Please check the appropriate checkboxes if your company possessed/used any of the following raw
chemicals or as chemical components in a certain raw chemical.
1,4- CHLOROBENZENE CHLOROP1CRIN METHYL CHLORIDE
1,2- DIBROMOETHANE CHROMIUM COMPOUNDS METHYLENECHLORIDE
O-DICHLOROBENZENE CYANIDE COMPOUNDS MIREX
1,4- DICHLOROBENZENE DIETHYL SULFATE PENTACHLOROPHENOL
1,2 DICHLOROETHANE ETHYLENE DIBROMIDE PERCHLOROETHYLENE
1,2 DIPHENYLHYDRAZINE ETHYLENE OXIDE PHENIC ACID
3-HYDROXYPHENOL GLUTARALDEHYDE PHOSGENE
ANTIMONYPENTACHLOR1DE FORMALDEHYDE PTHALIC ANHYDRIDE
ARSENIC COMPOUNDS HALONS POLYBROMINATEDBIPHENYLS
ASBESTOS HEXACHLOROBENZENE POLYCHLORINATEDBIPHENYLS
BENZENE HEXACHLOROETHANE 1,1,1 -TRICHLOROETHANE
BERYLLIUM COMPOUNDS HYDRAZINE TRICHLOROETHYLENE
CADMIUM COMPOUNDS LEAD COMPOUNDS TRIBUTYLTIN
CARBON TETRACHLORIDE Mercaptobenzothiazole (MBT) SELENIUM
CHLORINATED ETHERS MERCAPTAN,PERCHLOROMETHYL VINYL CHLORIDE
CHLOROFLUORO CARBONS MERCURY COMPOUNDS METHYL CHLORIDE
 N/A
Note: Above listed chemicals do not include chemicals contained in a consumer product e.g. fluorescent lamp, lead acid batteries, etc.

2) Please check the appropriate checkboxes of the Hazardous Wastes generated and indicate the corresponding
estimated generation per year.
Hazardous Waste Generation
Waste Type
Number (kg/yr)
A101 Cyanide Waste
L406 PCBs Waste
M502 Asbestos Waste
M501-M503 Medical Waste
D401-D499 Waste with Inorganic Chemicals
E501-E599 Reactive Chemical Waste
F602-F699 Inks/Dyes/Pigments/Paint/Resins/Latex/Adhesives/Organic Sludge
G703-G704 Waste Organic Solvents
K301-K303 Stabilized Waste
L401-L402 Other Organic Chemicals
M504-M506 Miscellaneous Waste
B201-B299 Acid Waste
C301-C399 Alkali Waste
1101 Oil Waste
J201 Empty Chemical Containers
H802 Putrescible Waste
D407 Busted fluorescent lamps
 N/A

3) Please check the appropriate checkboxes if your company provides any of the following services to another
company/clients, to wit:
Centralized Material Recovery Facility (MRF)
 Solid wastes treatment or processing facilities
 Sanitary Landfill
 N/A
 PCO-Form 03

4) Wastewater generation:
Domestic Wastewater:________m3/day
Process Wastewater:_________m3/day

5) Air Pollution Source Equipments (APSEs):

Ex. Generator sets, Fossil fuel fired boilers, Fossil fuel fired kiln dryers, Grinders, Crushers, etc.
Rated Capacity
Name of APSE Fuel Type
(Hp or kW or kVA)

Please attached additional sheets if

necessary

6) Please check the appropriate checkboxes if your wastewater contains any of the following
pollutants/contaminants/characteristics:
Arsenic
Cadmium
Chromium (hexavalent)
Cyanide
Lead
Mercury (total)
PCBs
Formaldehyde
 Wastewater has a raw BOD of greater than or equal to 3,000 mg/L
 N/A

7) Please check the appropriate checkboxes if yourcompany provides any of the following services to another
company/clients, to wit:
 Transport of Sludge
 Treatment of Sludge
 Transport of Hazardous Wastes
 Treatment, Storage and Disposal (TSD) of Hazardous Wastes
 Transport or treatment of wastewater, sewage and/or septage
 N/A

Establishment category based on the above information per DAO 2014-02:___________.

.______________________________
Name and Signature of PCO