MODULE 1: GENERAL INFORMATION

Reference No. :89371

Year :2022 Quarter: 3

Name of Plant : DR. MARIA ELENA IMPERIAL DENTAL CLINIC

Notes :
Health Care Facility: Clustered Dental Clinics Service Description: General Dentistry and
Orthodontics CLUSTERED DENTAL CLINICS: MEMBER OF CAVITE DENTAL CHAPTER INC. -
IMUS CLUSTER 4

DENR Permits/Licenses/Clearances

Environmental Laws Permits Date Issued Expiry Date

RA 9275
DP No. 0 DP-R4A-22-00658 2022-01-25 2023-01-25
PD 1586
ECC/CNC No CNC-OL-R4A-2021-07-05810 2021-07-20
RA 6969
DENR Registry ID OL-GR-R4A-21-012582 2021-11-23 2000-01-01
Transporter Registration NOT APPLICABLE 2000-01-01 2000-01-01
TSD Registration NOT APPLICABLE 2000-01-01 2000-01-01
CCO Registry NOT APPLICABLE 2000-01-01 2000-01-01
Importation Clearance No. NOT APPLICABLE 2000-01-01 2000-01-01
Permit to Transport OL-PTT-R4A-21-057308 2022-05-16 2000-01-01
Small Quantity Importation NOT APPLICABLE 2000-01-01 2000-01-01
Priority Chemical List NOT APPLICABLE 2000-01-01 2000-01-01
PMPIN NOT APPLICABLE 2000-01-01 2000-01-01
RA 8749
PO No NOT APPLICABLE 2000-01-01 2000-01-01

Operation

Operating hours/day Operating days/week # of shift/day

Average 6 5 1
Maximum 7 5 1

Operation/Production/Quality

Average Daily Production Output NOT APPLICABLE

Total Water Consumption this Quarter cm3 11
Total Output this Quarter NOT APPLICABLE
Total Electric Consumption 388
MODULE 2: RA 6969

A. CCO Report

CCO Item No. CCO Substance Common CAS No. Trade Name Intended Use Quantity Issued (in
Name/IUPAC/CAS CCO)
Index Name
No records found

For importers only

CCO Item Importation Quantity Quantity Date of Port of Entry Country of Country of Total Total
No. Clearance Issued (in IC) Imported Arrival Origin Manufacture Quantity Quantity
No. Requested Received
(annual) (annual)
No records
found

For Distributors (importers/non-importers)

CCO Item No. Name of Client License No. Quantity Date of Country of Country of Total Quantity
Distribution Origin Manufacture Distributed
No records
found

For non-importer users

CCO Item No. Name of Distributor Quantity Date of Purchase Total Quantity Purchased
from Distributor
No records found

For Producers

CCO Item No. Average Daily Production Total Output this Quarter Quantity of Stock Quantity of Stock
Output Inventory (Start of Quarter) Inventory (End of Quarter)
No records found

CCO Item No. Name of Buyer Quantity Date of Purchase Total Quantity Sold
No records found

Used in Production (please fill up only if chemical/substance is not main product)

CCO Item No. Average Daily Production Total Output this Quarter Average Quantity Used Total Quantity Used this
Output per month Quarter
No records found

Describe any changes in Production/Process/Operations

Stock Inventory/Waste Chemical Generated

 CCO Item No. Average Quantity of Waste Total Quantity of Waste Quantity of Stock Quantity of Stock
Chemical Generated per Chemical Generated this Inventory(Start of quarter) Inventory(End of quarter)
month Quarter
No records found

Other Information

Manner of Handling Hazardous Wastes Changes in Safety Management System Chemical Substitute Plan

B. Hazardous Wastes Generator

HW Generation

HW No. HW Class HW Nature HW Cataloguing Quantity Unit Quantity Unit

M501 Pathological or Solid Toxic (T) 0.0081 0.004
infectious
wastes
D402 USED LED Solid Toxic (T) 0 0
LIGHTS
D406 Lead Solid T/C 0 0
compounds
D407 Mercury and Solid Toxic (T) 0 0
mercury
compounds
I101 Used industrial Liquid Flammable (F) 0 0
oil including
sludge
J201 Contaminated Solid Toxic (T) 0 0
Containers
M503 Pharmaceuticals Solid Toxic (T) 0 0
and drugs
M506 Pharmaceuticals Solid Toxic (T) 0 0
and drugs

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 Action Taken
2022-07-01 Storage Area of Hazardous Compliant with the minimum Continuous Improvement in
Wastes standard set forth in DAO compliance with RA 6969
2013-22
2022-08-01 Storage Area of Hazardous Compliant with the minimum Continuous Improvement in
Wastes standard set forth in DAO compliance with RA 6969
2013-22Compliant with the
minimum standard set forth in
DAO 2013-22
2022-09-01 Storage Area of Hazardous Compliant with the minimum Continuous Improvement in
Wastes standard set forth in DAO compliance with RA 6969
2013-22
--
C. Hazardous Wastes Treater/Recycler

HW Stored and/Untreated as of End of Quarter

Type of Waste HW Number Wastes Date of Transport Quantity Type of Storage Time Table for
Generator Transport Permit/Date of Container/# of Treatment
Issue Containers

HW Treated and/or Recycled as of End of Quarter

Type of Waste HW Number Wastes Date of Transport Quantity Type of Quantity of

Generator Transport Permit/Date of Treatment of Recycled or
Issue Recycling Treated Product
Process

Residual Wastes Generated from the Treatment and/or Recycling Operation

Type of Waste HW Number Process by which Quantity Type of Storage Disposal Option Time Table for
the Waste is Containers/# Disposal
Generated Number of
Containers
MODULE 3: RA 9275

Water Pollution Data

Domestic wastewater (cubic 0.010 | Process wastewater (cubic N/A

meters/day) : meters/day) :

Cooling water (cubic meters/day) N/A | Others : N/A

:

Wash water, equipment (cubic 0.010 | Wash water, floor (cubic 0.010
meters/day) : meters/day) :

Record Cost of Treatment

Month 1 Month 2 Month 3

Person employed, (# of N/A N/A N/A
employess)
Person employed, (cost) N/A N/A N/A
Cost of Chemicals used by WTP N/A N/A N/A
Utility Costs of WTP(electricity & N/A N/A N/A
water)
Administrative and Overhead N/A N/A N/A
Costs
Cost of operating in-house N/A N/A N/A
laboratory
New/Additional investment in N/A N/A N/A
WTP (description)
Costs of New/Add Investments N/A N/A N/A

WTP Discharge Location

Outlet Number Location of the Outlet Name of Receiving water body

1 IN FRONT OF THE BUILDING OF EACH WASTEWATER ARE COLLECTED IN
CLINIC SEPTIC TANK (NEAREST WATER BODY
IMUS RIVER)

Detailed Report of Wastewater Characteristics for Conventional Pollutants

Outlet No. DATE Effluent Flow BOD (mg/L) TSS (mg/L) Color Ph Oil & Grease Temp Rise Unit
Rate (mg/L) (C)
(m3/day)
N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A

Detailed Report of Wastewater Characteristics for Other Pollutants

Outlet No. DATE Effluent Flow

Rate
(m3/day)
/ / / / / / /
N/A N/A N/A N/A N/A N/A N/A N/A N/A
N/A
MODULE 4: R.A. 8749 (Air Pollution)

Summary of APSE/APCF

Process Equipment. Location # of hours of operation for the quarter

Fuel Burning Equipment Location Fuel Used (indicate % if Quantity Consumed for the# of hours of operations for
mixed composition) quarter the quarter

Pollution Control Facility Location # of hours of operation for the quarter

Record Cost of Treatment

Month 1 Month 2 Month 3

Detailed Report of Air Emission Characteristics

FBE No. DATE Flow Rate CO NOx Particulates

(Ncm/day) (mg/Ncm) (mg/Ncm) (mg/Ncm)
MODULE 5: P.D. 1586

Ambient Air Quality Monitoring (if required as part of ECC conditions)

Station DATE Noise Level CO NOx Particulates (mg/Ncm) (mg/Ncm) (mg/Ncm) (mg/Ncm)
Description (dB) (mg/Ncm) (ng/Ncm) (mg/Ncm)
2000-01-01

Ambient Water Quality Monitoring (if required as part of ECC conditions)

Station DATE / / / / / / / /
Description
2000-01-01

Other ECC Conditions

ECC Condition/s Status of Compliance Actions Taken

N/A No N/A

Environmental Management Plan/Program

Enhancement/Mitigation Measures/s Status of Compliance Actions Taken

N/A No N/A

Solid Waste Characterization/Information

Recyclable Biodegradable Residual

Average Quantity Generated 0.0001 0.0001 0.0001
(tons/ month)
Total Quantity Generated (tons/ 0.0003 0.0003 0.0003
quarter)
Average Quantity Collected (tons/ 0.0001 0.0001 0.0001
month)
Total Quantity Collected 0.0003 0.0003 0.0003
(tons/quarter)
Entity in charge of collection LGU Solid Wastes Hauler LGU Solid Wastes Hauler LGU Solid Wastes Hauler

Brief Description of Solid Waste Management Plan (e.g., waste reduction, segregation, recycling)

Waste materials that will be generated are in the form of cartons, papers, plastic bags & damaged
packaging materials. Other solid wastes come from office are papers, cartons and other
biodegradable / non – hazardous wastes and left-over foods if any. Proper solid waste management
such as segregation at source are being implemented and such wastes are collected to in bin/s prior
to regular disposal.
MODULE 6: OTHERS

Accidents & Emergency Records

Date Area/Location Findings & Observation Actions Taken Remarks

N/A N/A N/A N/A N/A

Personnel/Staff Training

Date Conducted Course/Training Description # of Personnel Trained

2022-09-25 CDC EMB 4A TECHNICAL CONSULTATION 1
I hereby certify that the above information are true and correct.

Done this , in IMUS CITY, CAVITE.

Dr. Febe Marie S. Suarez

__________________________________
Name/Signature of PCO

Dr. Maria Elena Imperial

__________________________________
Name/Signature of CEO

SUBSCRIBED AND SWORN before me, a Notary Public, this day of

, affiants exhibiting to me their Community Tax Receipts:

Name ID No. Issued at Issued on

Dr. Febe Marie S. Suarez
DR. MARIA ELENA IMPERIAL