General Quality Form

SUBIC BAY METROPOLITAN AUTHORITY ECD-RPD-29

ECOLOGY CENTER
Regulatory Bldg., Labitan St. cor. Rizal Highway, Subic Bay Freeport Zone, Philippines 2222 Revision No.: 08
Tel 047.252.4656/4059; Fax 047.252-4157; email: ecology@sbma.com
Effectivity Date: 9/16/19

APPLICATION FOR ENVIRONMENTAL CLEARANCE FOR VARIOUS ACTIVITIES

Part 1. Basic Information (This portion to be filled out by Applicant):
Name of Applicant: _____________________________ Company: _______________________ Contact No.: _____________________
Pls check applicable box: Locator Contractor Other (please specify or describe)___________________________________________
REQUIRED TO SECURE CLEARANCE BY Seaport Dept. LED LAMD Bureau of Customs BPSD Others ____________
PROPOSED ACTIVITY: ____________________________________________________________________________________________
DESCRIPTION OF THE PROPOSED ACTIVITY: __________________________________________________________________________
EXACT LOCATION OF ACTIVITY/PROJECT ____________________________________________________________________________________________

Part 2. (Pls. check all applicable box) DOCUMENTS/ATTACHMENTS SUBMITTED IN SUPPORT TO REQUEST:
Site dev’t plan, vicinity map, location map for the proposed project
PROPOSED ACTIVITY INVOLVES -
Photos related to the proposed project with proper labels
Cutting/trimming/relocation of trees and other plants
Copy of SBMA’s Accreditation (if will tap the services of a contractor)
Disposal of solid waste and/or hazardous waste
Copy of ECC/CNC issued to the Company for this particular area, scope or
Excavation/Dredging
project or other official document such as NTP, MOA, DOU, etc.
Hauling of construction debris
Part 3. if proposed activity involves bunkering or fuel loading, pls. fill in the following required information:
Mode of Bunkering: Truck-to-truck Truck-to-ship/vessel Ship-to-ship (vessel-vessel) Facility pipeline-to-ship/vessel
If Fuel Loading by Facility Pipeline, indicate name of Facility: ______________________ If using truck, indicate type & plate no.:______
Name of Ship/Vessel/Barge to be refueled: _____________ _____________________________________________________________
Fuel/Oil Requirements: Marine Gas Oil Intermediate Fuel Oil Lube Oils Others________________________
Volume Required: _____________________liters or ________________________metric tons
Validity Date Requested (Date/Period of Bunkering/Loading Activity: _________________ Assigned Berth: _______________________
Name of Supplier/Fuel Provider/Transporter: _________________________________________________________________________
Name of Barge to be used to provide fuel: ___________________________________________________________________________
Supplier Accredited/Registered by SBMA as Petroleum Hauler using only “authorized” trucks/vehicles or vessels,
e.g., w/ PASSED emission test)? Yes No (Note: A copy of the valid Accreditation Certificate may be required for verification)
Requested by (Name of Person indicated in Official Request): ____________________________________________________
Name of Company Represented: ____________________________________ Contact No./s.: __________________________
Part 4. If activity requires use of personnel and entry of vehicle/s, pls Indicate name/s of personnel and designation and
vehicle’s Make/Model & Plate No./s: ______________________________________________________________
___________________________________________________________________________________________
(USE ADDITIONAL SHEET/S IF NECESSARY)
Part 5. Pls. sign here:
__________________________________________________________________
Applicant’s (Declarant’s) Printed Name and Signature:
Date/Time Applied: ________________________________ Contact No./s.: _____________________________________________
Part 6: Evaluation (Please do not write beyond this point. This portion to be filled out by Ecology Center staff)
Request Received by: ________________________________________ Date/Time Received: _____________________________________
Activity applied for is covered by any of the following:
For Locator, with the ff. Environmental Permit for this particular activity & location? - ECC CNC NTP
For Service Contractor, with Certificate of Accreditation as Ship’s Agent as Petroleum Hauler Other (specify) _________________
Visiting/Non-Accredited Agency/Company ____________________________________________________________________________________
Also with the following required attachments:
Written Instruction from Seaport Dept. regarding bunkering
Bureau of Customs (BOC)’s Subic Bunkering Permit/Clearance Others (pls. describe) _____________________________________
If Authorized Representative, w/Letter of Authorization? YES NONE. Pls. provide by date: ____________________ Not Required
EVALUATOR’S RECOMMENDATION: Grant Clearance Deny Clearance Grant Clearance Only If: _________________________
Remarks: ___________________________________________________________________________________________________________

Evaluated by: Noted by: Date/Time Evaluation was Completed:

__________________________________ ______________________________ _______________________________
(Case handler to Sign over Printed Name) EC Authorized Signatory