Republic of the Philippines

Department of Environment and Natural Resources

Environmental Management Bureau-National Capital Region
National Ecology Center Compound, East Avenue, Diliman, Quezon City

APPLICATION FOR DISCHARGE PERMIT

Type : New Renewal Extension/Conversion

Change of Ownership Change of Name Modification/Amendment

INSTRUCTION: Fill in all appropriate white spaces. Mark all appropriate boxes with an "X"
BOX A: General Information

Name of Applicant

Address

Name of Establishment TIN:

Est. Code: Year Est.

Plant Address No. & Street Name Barangay

City or Municipality Region National Capital Region

Type of Industry

Name of PCO Accreditation Date

Tel. No. & Cel.No. Fax No.:

Legal Classification Proprietorship Private Corp. Multi-National Others: Specify

Ownership Terms Private % Foreign % Government %

BOX B: Employment and Operation Information

Total employment (number of workers) in the factory: Production Non-Production

Production Time: No. of hours/day No. of days/mo. No. of mos./year No. of days w/ discharge/mo.

BOX C: Sources of Water Supply and Wastewater Generation

Sources of Water Supply Monthly ave. daily ave. Generating Process Estimated Flow
vol. (m3) vol. (m3) (m3/day)
MWSS (please attach water bills) Process Wastewater

Local Water District (please attach water bills) Washing/Cleaning of Process Eqpt.
Deep Well Cooling
Surface water (lake, river, creek, etc.) Domestic
Others Recycled/Reuse
Others (drinking water, gardening,
evaporation, leaks, products components, etc.)
Total Water Consumption Total Volume of Discharge Wastewater
BOX D: Dwelling Units Information (hotels, condominium, restaurants, malls, etc.)

Total Floor Area (m2) No. of Bedrooms No. of Guests/year

Total Area for Dining Units No. of Restaurants/Dining Units

BOX E: Product Information

Product 1 Product 2 Product 3 Product 4

Product Name**

Annual Production Capacity

Actual Production in the previous year

Type of Process Batch Continous Batch Continous Batch Continous Batch Continous

BOX F: Water Pollution Information

Location & Description Name of the Receiving Body Ave. BOD, mg/L Ave. Rate of Ave. BOD Load,
Outlet Number of the Outlet of Water Discharge, m3/day kg/day

1
2
Total

FM-CPD-AW09 00 10-15-17
BOX G: Flow Meter Information

Flow meter is installed at: Influent Effluent Both Total Plant Effluent None

Type of flow meter and method used at (effluent side): Parshall Rectangular weir Triangle weir Venturi meter
Flume

Direct Reading Area Velocity Method

If others, please specify device and/or method:

BOX H: Information on the Wastewater Treatment System

Wastewater treatment system existing? Yes No If YES, what is the capacity m3/day

Value of capital investment in the wastewater treatment plant. Pesos

Is there a primary treatment system? Yes No Date primary system installed : Month Year

If Yes, what is the composition of the physical treatment system?

Screening Equalization Grit Removal Oil-Water separation Sedimentation If others, specify

(Flotation) (Primary Settling)

Is there a chemical treatment? Yes No Date chemical treatment installed: Month Year

If Yes, what is the composition of the chemical treatment system?

Adsorption Disinfection Flocculation/coagulation pH Adjustment If others, specify

Is there a secondary treatment system? Yes No Date installed : Month Year

Activated Sludge Single Batch Reaction Anaerobic Digestion Oxidation/Stabilization (Pond)

Trickling Filtration Rotating Biological Contact If others, specify

BOX I : Vicinity Map (the map should show relative location of the establishment with respect to existing structures, landmarks, rivers, the lake and other
water bodies, etc., use scale to fit into the frame below)

Note: **Please use generic name. Not brand names, in metric tons of products except for the following subsectors : hog raising (heads),
carbonated drinks and beers (m3), slaugthering/preserving meat (ton LWK, electroplating (m2)).

I hereby certify that the above information are true and correct to the best of my knowledge. Done this ___________________ day of
________________, ________.

Name and Signature of the Pollution Control Officer Chief Executive Officer
(Name, Signature and Position)

SUBSCRIBED AND SWORN to before me a Notary Public, This _____ day of _________________, affiant exhibiting to me his/her Community Tax
Receipt No. _______________________________, issued at _____________________________, on ____________________.

NOTARY PUBLIC

Application No. ______________________

FM-CPD-AW09 00 10-15-17