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Republic of the Philippines

Department of Environment and Natural Resources
ENVIRONMENTAL MANAGEMENT BUREAU
Region IX, Zamboanga Peninsula
Lantawan, Pasonanca, Zamboanga City
Tel No: (062) 985-0428

APPLICATION FOR PERMIT TO OPERATE

Air Pollution Source Installations

A. General Information
Application No.
Application Type
Name of Owner
Name of Establishment

Mailing Address

Zip Code
Mailing Tel.No. Mailing Fax No.

Plant Name
Plant Address
Plant Zip Code
Plant Geolocation
Plant Tel.No. Plant Fax No.

B. Company Information
TIN Nature of Ownership
EIA Classification
Nature of Business
Authorized Capital Paid up capital
Date of Start of Operation
ECC Number
CNC Number
Managing Head Tel. No.
Name of PCO Tel. No.
PCO Designation
PCO Accreditation
PCO Accreditation No
Validity

C. Other Company Related Information

Office Operation (hrs/day) Office Operatation (days/week)
Production Operation (hrs/day) Production Operation (days/week)
7Total Employees
Land Area Land Use
Land Ownership
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D. Raw Material and Product Information

Raw Material Quantity Product Quantity

E.1 Air Pollution Sources Installation (APSI) for Fuel Burning Subject for Permitting
Standy
APSI Brand Type of Date Technical
APSI Generator Capacity Remarks
Name Name Fuel Installed Description
Set?
Other
sources of
air pollution

E.2 Air Pollution Sources Installation (APSI) for Non Fuel Burning Subject for Permitting
Technical
APSI APSI Name Capacity Brand Name Raw Material Date Installed
Description
Other sources
of air pollution

E.3 Air Pollution Control Device (APCD) Subject for Permitting

APCD Description Capacity Remarks

E.4 Stacks
Name Height Diameter Temperature Velocity

F. APSI APCD Mapping

Connected APSIs Connected APCDs Connected Stacks
ID APSI
(<name> (id)) (<name> (id)) (<name> (id))
1
2

Connected APSIs Connected APCDs Connected Stacks

ID APCD
(<name> (id)) (<name> (id)) (<name> (id))
1

NOTARIZED CERTIFICATION

We hereby certify that the above information are true and correct to the best of my knowledge. Done this
day of of .

Pollution Control Officer Managing Head

SUBSCRIBE AND SWORN to before a Notary Public this day of .

Affiant exhibiting to Officer Officer me his/her government issued ID with no. .
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NOTARY PUBLIC