MODULE 1: GENERAL INFORMATION Reference No. :95572 Year :2022 Quarter: 4 Name of Plant : JCA GASOLINE STATION Notes : DISCHARGE PERMIT IS ACQUIRED AND DISPLAY ON THE OFFICE The fine from PAB CASE 08-000027-22-W fully paid. see attachment of the receipt DENR Permits/Licenses/Clearances Environmental laws [Permits Date Issued Expiry Date D5. DEKE DEROEIOGTT BO TO BOSTO2 EE ECCIENE No ESC-OL-ROS-2O1-0007 DOTOTD, PAGS, DENR Registy © TWA 2o0607o1 200-01 Transporter Registration NWA 2000-07-01 2000-01-01 "TSO Registration WA 2000-07-01 2000-01-04 (COO Registy WAL 2000-07-01 2000-07-01 (CCO Registy NA 2000-01-04 2000-01-01 Traportaton Clearance No WA 2000-07-01 2000-07-01 importation Clearance No. WAL 2000-07-01 2000: Permit to Transport WA 2000-07-01 [2000-01-07 Permt to Transport WA 2000-01-01 2000-01-01 ‘Sioa Quant importation WA 2000-01-01 "2000: ‘Small Quantity Importation iN [2000-01-01 2000-07-01 Proity Chemical ist NWA 2000-07-01 [2000-01-07 Reo is racers —| — aos OT Operation ‘Operating hoursMday | Operating dayshveek For sniaay Averay 14 7 1 [a eee ere Z Ea bre 7 Operation/Production/Quality ‘Average Daly Production Output B55 44 Uhre “Total Water Consumption this Quarter om 115 “Total Output this Quarter TERA 685 Liars Total Electric Consumption 7103MODULE 2: RA 6969 A. CCO Report ‘CCOTeEM No, | CGO Substance | Common CAS No. | Trade Name] intended Use [Ouantty osue3 7] fom UPACI cco) Index Name To esorde found For importers only ‘SEO em [importation] Guantty | Guensly | Date of [Por of Ent] County of | County ot] Tota] Tatar No. | Clearance }ssued (inIC] Imported | Arrival Origin [Manufacture] quantty | uantity No. Requested | Received annual) | (annual) No records | found For Distributors (importers/non-importers) CoO RenNe, [Rare acter] Lense] Charly Dales | Couneyot | Coonty of] Toa any Distrbution | “origin | Manufacture | Distributed No records | found For non-importer users TCO Kem No. Tama of Dietibitor No records found Guantiy Date of Purchase] Total Guanitly Purchased ‘rom Distributor For Producers SCO Tem No. [Average Dally Production] Total Output is Quarter] —Guantiy of Stock Guantty of Stock Output Javentory (Start of Quarter} inventory (End of Quarten| (ierecords found TCO Tem No- Tame of Buyer Guar No records found Used in Production (please fill up only if chemical/substance is not main product) Date of Purchase otal Guantiy Soe CEO Tem Ne. [Average Dally Production Output Total Output is Quarter ‘rerage Quantiy Used per month, Total Quanity Used his Quarter No records found Describe any changes in Production/Process/Operations Stock Inventory/Waste Chemical Generated(COOTemNo, — Piverage Guantty of Wesid) Total Guantiy of Waste" | —Guantiy of Sak —] —Guanliy of Staak Chemical Generated per | Chemical Generated this [inventory Start of quarter] inventory(End of quate) month ‘Quarer No records found I al Other Information Re B. Hazardous Wastes Generator ner of Handing Hazardous Wastes _|_Changes in Safely Management System Chemical Substtute Plan I HW Generation Hane [AW Gass [Hate — ng] — cua Th uaniiy + TE Te reons al ea Waste Storage, Treatment and Disposal(please fill-up one table per HW) On-site self Inspection of Storage Area [Date Conducted] Premises/Area inspected | Findings and Observations —[ Corrective Acton Taren —] C. Hazardous Wastes Treater/Recycler HW Stored and/Untreated as of End of Quarter Type of Waste | HW Number | Wastes Date of —] Transpot | Guantiy Type of Storage] Time Table for Generator | Transport | PermitDate of Containeri# of | Treatment Issue Containers HW Treated and/or Recycled as of End of Quarter Type ofWaste | HWNumber | Wastes Date of Transport | uantiy Type of] Guantiy of Generator | Transport | PermitDate of Treatment of | Recycled or Issue Recyeling [Treated Product Process. Residual Wastes Generated from the Treatment and/or Recycling Operation Type of Waste] HWNumber [Process by which] the Waste is ‘Quantity | Type of Storage Containers/# Disposal Option | Time Tak Disposal TerGenerated Number of ContainersMODULE 3: RA 9275 Water Pollution Data Domestic wastewater (cubic e | Process wastewater (cubic a mmetorsiéay) metersiday) Cooling water (cubic meters/day) ala 1 Others Wash water, equipment (eubie ala | Wash water, floor (cubic ia meters) rmetersiday) Record Cost of Treatment Tent Tien Tons Parson employed, ot va a ma employes) Person employed, (coat) ma Wa wa [Gost of Chemicals used by WIP] a wa ma Unity Costs of WTPelectroty &| a a ma water “Raina and Overhead Wa Wa Wa Costs Tost of operating irhouse Wa Wa 7 laboratory NewAdiional investment Wa Wa Wa WTP (description) ([eaais ot Newaas investments wa Ta or WTP Discharge Location ‘Suet number Location othe Out Thais of Receving water bod i THSIDE THE establishment wan ver Detailed Report of Wastewater Characteristics for Conventional Pollutants ‘OulletNo.] DATE [effluent Flow BOD (mg/L)] TSS (mgi)] Color PR [OIE Grease] Temp Rise | Unt Rate (mg) (c) (m3iday) Wa [2000-07-07] wa Ta na wa wa | va wa a Detailed Report of Wastewater Characteristics for Other Pollutants Rate (ma/day) ‘Outlet No] DATE Pe Flow Ceo Cooley TaMODULE 4: R.A. 8749 (Air Poll Summary of APSE/APCF Process Equa Tosaton [i othours of operator forthe quater TRDERGROUND TANK PREMIUM —[ —WiTFINTTHE ViGNITY OF THE FUEL 260 STATION UNDERGROUND TANK UNLEADED? | WITHIN THE VICINITY OF THE FUEL 7250 STATION TROERGROUND TANK DESELS | —WITHINTRE VIGINTY OF THE FUEL 7250 STATION | UNDERGROUND TANK PREMIUM 4 | WITHIN THE VICINITY OF THE FUEL 71260 STATION UNDERGROUND TANK DIESEL § | WITHIN THE VICINITY OF THE FUEL 735 STATION Fuel Burning Equipment I Location Fuel Used (indicate % if fae "Consumed for thel# of hours of operations fod Tixed compostion) er the quarter Poltion Control racity Tocation Wot hours of operation forthe quarter —] Record Cost of Treatment [ I Vout I Moz I Monn ] Detailed Report of Air Emission Characteristics FEENo. | DATE | FowRate] CO NOx [Particulates] (Nomisay) | (mg/Nem) | (mg/Niom) | (ma/bicm) (12000-5757MODULE 6: OTHERS Accidents & Emergency Records 2000-01-01 2000-01-01 Personnel/Staff Training Course/Training Description 40 HRS BASIC TRAINING COURSE FOR ee POLLUTION CONTROL OFFICER H 2000-01-01Thereby certify that the above information are true and correct Done this A M. CABILAN JR. SUBSCRIBED AND SWORN before me, a Notary Public, this day of SAN 05 2023 jn Toclban Oty affiants exhibiting to me their Community Tax Receipts Name ID No. Issued at Issued on [ARCALES 00 SAMAR 98/33/2020 DANILO M. Ho4-20- - BORONGAN EASTERN CABILAN JR 000562 SAMAR 95/23/2020 sevsme 9 | wih we sae 1 BIT |