Department of Environment and Natural Resources

Environmental Management Bureau

Please indicate the Region Please attach your
REGION II 2” x 2” picture
Pollution Control Officer (PCO) Accreditation Revision No. 1 here
Application Form (New) Page 1 of 3

Instructions:
Fill in all the data needed. If the blanks are not applicable, write N.A.
PROFILE
Last Name First Name Middle Name Sex: Citizenship:
 Male
DULIN ABEL SIBBALUCA Female FILIPINO
Home Address (Number & Street, Town/City, Employment Current Position:
Province, Zip Code) Status: LIAISON OFFICER
 Full-time No. of Years in
ZONE 2, ALIMANNAO, PEÑABLANCA, Current Position: 3
CAGAYAN 3502 Part-time
Effectivity of Appointment
Others as PCO:

Telephone No.: Cellular Phone No.: E-mail Address: abeldulin9@gmail.com

N/A +639752778683
ACCREDITATION INFORMATION
Project Name / Establishment Name: Name of Managing Head:
TIMOTEO D. SIBBALUCA
TTS GASOLINE STATION Position:
OWNER/MANAGING HEAD
Project Location Address (Number & Street, Nature of Business Establishment Category
Town/City, Province, Zip Code) of the based on DAO 2014-02:
Establishment:
ZONE1, DODAN HIGHWAY, DODAN, CATEGORY A
PEÑABLANCA, CAGAYAN, 3502 GASOLINE
REFILLING
STATION
Telephone No.:CP no.: Fax No.: Website:
N/A N/A
+639174768022
✓ QUANTITY & CLASSIFICATION:
Handling / Storing Chemicals
Listed in Annex 1 of DAO 2014-02
Hazardous Waste Generated:

With Centralized MRF / Sanitary

Landfill:
Generator Set / Boiler Capacity
(Kw / KvA / Hp):
Waste water discharged (cu.m/day):

Transporter / Treater of Sludge:

Other Sources of pollution:

 Department of Environment and Natural Resources
Environmental Management Bureau
National Capital Region
Pollution Control Officer (PCO) Accreditation Revision No. 1
Application Form (New) Page 2 of 3
HIGHEST EDUCATIONAL ATTAINMENT
School Address Inclusive Dates Degree/Units Earned
INTERNATIONAL ALIMANNAO HILLS, BACHELOR OF SCIENCE
SCHOOL OF ASIA PEÑABLANCA, IN INFORMATION
AND THE PACIFIC CAGAYAN TECHNOLOGY

Type of PRC License received (if any):

PRC License No.: Date Issued: Validity:

WORK EXPERIENCE (Use additional sheet if necessary. Please attach photocopy of Certificate
of Employment)
Status of Employment
Company Position Inclusive Dates

ENVIRONMENT RELATED TRAININGS / SEMINARS ATTENDED (Use additional sheet if

necessary. Please attach photocopy of certificate.)
Title of Training/ Conducted No. of
Venue Date/s Certificate No.
Seminar by Hours
BASIC TRAINING DENR-EMB- WEAP 11/9- 40 EMB-R2-PCO-CA-
COURSE FOR REGION 02 13, 2020-11-13-178
POLLUTION OFFICE 2020
CONTROL OFFICERS
 Department of Environment and Natural Resources
Environmental Management Bureau
National Capital Region
Pollution Control Officer (PCO) Accreditation Revision No. 1
Application Form (New) Page 3 of 3
OTHER REQUIREMENTS (Please attach the following requirements)
Letter of appointment/designation as PCO/Managing Head of the establishment

Curriculum vitae with ID Picture of the appointed/designated PCO

Certificate of Full Time employment appointed as PCO.

Copy of Diploma or TOR of the designated PCO.

Notarized Affidavit of Joint Undertaking of the PCO and the Managing Head
Certificate of Training for forty (40) hours of Basic PCO Training (Attended within the
last 3 years)
For the Managing Head, Certificate of Training for eight (8) hours on environmental
management
For Category B Establishments, include copy of valid Professional Regulation
Commission License, if applicable.
Processing Fee of Php 500.00.

Do you have any pending

a) Administrative case Yes ✓ No b) Criminal case Yes ✓ No

If you have any, give details of the case _________________________________________

I certify that all the information stated above are true and correct.

ABEL S. DULIN ABEL S. DULIN

Name and Signature of Applicant / Date

Verified by:

_____________________________________________
Name and Signature of EMB Personnel / Date