Department of Environment and Natural Resources

Environmental Management Bureau

Reference No:

(to be filled up by DENR only)

GENERAL INFORMATION SHEET

Name of the
MC & JOLLI FOODS
Establishment/Facility

Establishment/Facility Street # & Street Name: 123 Maria Makiling St. ___
Address Barangay: Brgy. Silangan, City/Municipality: Rosario___
(NOT the company of head
office) Province: Cavite
Name of
UNITED FOODS, INC.
Owner/Company
Street # & Street Name: 123 Maria Makiling St. ___
Address
(if address is not the same as Barangay: Brgy. Silangan, City/Municipality: Rosario___
previous address)
Province: Cavite

Phone Number 046-1234567 Fax Number N/A

operations@unitedfoods.com
e-mail address

Philippine Standard Industry Classification Code No. 107 ___

Type of Business/
Philippine Standard Industry Descriptor: Food Manufacturing ___
Industry Classification
___

CEO/President. Analea de Guzman; ___

Tel #: 046-1234567 Fax #: N/A ___
e-mail address: analea.deguzman@unitedfoods.com ___
Responsible Officer/s:
Plant Manager: ___
Tel #: Fax #: ___
e-mail address: ___

Name. Ryan Reyes ___

Pollution Control
Tel #: 046-7654321 Fax #: ___
Officer
e-mail address: 046-7654321 ___

 single proprietorship  partnership

Legal Classification  private domestic corporation  government corporation
 Multi-national  ___

We hereby certify that the above information are true and correct.
 Department of Environment and Natural Resources
Environmental Management Bureau

Reference No:

(to be filled up by DENR only)

Name/Signature of CEO/President Name/Signature of PCO
Name of Plant:
Reference No:

Department of Environment and Natural Resources

Environmental Management Bureau

QUARTERLY SELF-MONITORING REPORT

MODULE 1: GENERAL INFORMATION

Name of the Plant MC & JOLLI FOODS
Please provide the necessary revised, corrected or updated information not contained in your General
Information Sheet

(use additional sheet/s if necessary)

DENR Permits/Licenses/Clearances
Environmental
Permits Date of Issue Expiry Date
Laws
A/C No. N/A N/A N/A
P.D. 984
PO No. DP-2201-0987 Oct. 10, 2021 Sept. 30, 2026
ECC 1 ECC-4A-2016-1234-0987 April 22, 2020
PD 1586 ECC 2 N/A N/A N/A
ECC 3 N/A N/A N/A
DENR
Registry ID OL-GR-4A-12-45678 May 25, 2021
CCO Registry N/A N/A N/A
RA 6969 Importer
Clearance No N/A N/A N/A
Permit to
Transport N/A N/A N/A
A/C No. N/A N/A N/A
RA 8749 June 13, 2026
PTO No. 2021-POA-0123-999 June 14, 2021

Module 1: General Information page ____ of ____

Name of Plant:
Reference No:

Operation
Operating hours/day Operating days/week # of shift/day
Average 16 6 3
Maximum 20 6 3

Operation/Production/Capacity:
Average Daily
0.95 MT Total Output this Quarter 74 MT
Production Output
Total Water Consumption Total Electric
this Quarter (cubic 1987 cu.m Consumption this Quarter 29,520 kwH
meters) (KwH)
Please use additional sheet/s if necessary

Module 1: General Information page ____ of ____

Name of Plant:
Reference No:

MODULE 2: RA 6969

A. CCO Report (please accomplish this section for each chemical/substance)

Common Name/IUPAC/CAS Index Name. N/A ___

CAS No.: ___
Trade Name: ___

For importers only:

Import
Quantity Date of Quantity Country of Country of
Clearance Port of Entry
Requested Arrival Received* Origin Manufacture
No.
N/A N/A N/A N/A N/A N/A N/A

Total Quantity Requested Total Quantity Received

(annual) (annual)
* attach copy/s of Bill of Lading

For distributors (importers/non-importers)

Name of Client License No. Quantity Date of Distribution
N/A N/A N/A N/A

Total Quantity Distributed

For non-importer users:

Name of Distributor Quantity Date of Purchase
N/A N/A N/A

Total Quantity Purchased from Distributor

For producers

Module 2B: RA 6969 (Hazardous Wastes Generator) page ____ of ____

Name of Plant:
Reference No:

Average Daily
N/A Total Output this Quarter N/A
Production Output
Quantity of Stock N/A Quantity of Stock N/A
Inventory (Start of Inventory (End of
Quarter) Quarter)
Name of Buyer Quantity Date of Purchase
N/A N/A N/A

Total Quantity Sold

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

Average Daily
N/A Total Output this Quarter N/A
Production Output
Average Quantity Used N/A Total Quantity Used this N/A
per month Quarter
Describe any changes in Production/Process/Operations:

N/A

Stock Inventory/Waste Chemical Generated:

Average Quantity of N/A Total Quantity of Waste N/A
Waste Chemical Chemical Generated this
Generated per month Quarter
Quantity of Stock N/A Quantity of Stock N/A
Inventory (Start of Inventory (End of
Quarter) Quarter)

Other Information:
Manner of handling  storage on-site  Treatment on-site
hazardous wastes  storage off-site  Treatment off-site

Changes in Safety  Yes (please attach copy of revised plan)

Management System  No

Chemical Substitute  Yes (please attach copy if not submitted/included in previous report/s or had been revised)
Plan  No
B. Hazardous Wastes Generator

Module 2B: RA 6969 (Hazardous Wastes Generator) page ____ of ____

Name of Plant:
Reference No:

HW Generation:
Remaining HW from
HW HW Generated
HW No. HW Class HW Nature Previous Report
Cataloguing
Quantity Unit Quantity Unit
I101 Used Oil Liquid T, I 160 Kg 560 Kg
H802 Grease Liquid T 100 Kg 200 Kg
Wastes
D407 Busted Solid T 9.20 Kg 9.20 Kg
Fluorescent
Bulbs
J201 Waste/ Solid T 20.85 Kg 20.85 Kg
Contaminated
Containers
M506 WEEE Solid T 1 kg 1 Kg

Waste Storage, Treatment and Disposal:(Please fill-up one table per HW)
HW No,: I101 (Used Oil) ___
HW Details Qty of HW Treated: 560 Unit: kg ___
TSD Location: Offsite ___

Name: MC & JOLLI FOODS ___

Storage
Method: Placed In Steel Drums ___

ID: 2021-0943 Name: XYZ Corp ___

Transporter
Date: April 6, 2022 ___

ID: 2021-1234 Name: ABC Corp ___

Treater
Method: Chemical Treatment Date: April 7, 2022

ID: 2021-1234 Name: ABC Corp ___

Disposal
Method: Chemical Treatment Date: April 7, 2022

HW No,: H802 (Grease Wastes) ___

HW Details Qty of HW Treated: 200 Unit: kg ___
TSD Location: Offsite ___

Name: MC & JOLLI FOODS ___

Storage
Method: Placed in Plastic Drums ___

ID: N/A Name: N/A ___

Transporter
Date: N/A ___

ID: N/A Name: N/A ___

Treater
Method: Date: ___

Module 2B: RA 6969 (Hazardous Wastes Generator) page ____ of ____

Name of Plant:
Reference No:

ID: Name: ___

Disposal
Date: Date: ___

HW No,: D407 (Busted Fluorescent Lamps) ___

HW Details Qty of HW Treated: 9.2 Unit: kg ___
TSD Location: Offsite ___

Name: MC & JOLLI FOODS ___

Storage
Method: Placed In Plastic Drums ___

ID: N/A Name: N/A ___

Transporter
Date: N/A ___

ID: N/A Name: N/A ___

Treater
Method: Date: N/A ___

ID: N/A Name: N/A ___

Disposal
Date: N/A Date: N/A ___

HW No,: J201 (Waste/ Contaminated Containers) ___

HW Details Qty of HW Treated: 20.85 Unit: kg ___
TSD Location: Offsite ___

Name: MC & JOLLI FOODS ___

Storage
Method: Placed In Wooden Crate & Pallet ___

ID: N/A Name: N/A ___

Transporter
Date: N/A ___

ID: N/A Name: N/A ___

Treater
Method: Date: N/A ___

ID: N/A Name: N/A ___

Disposal
Date: N/A Date: N/A ___

HW No,: M506 (WEEE) ___

HW Details Qty of HW Treated: 1.0 Unit: kg ___
TSD Location: Offsite ___

Name: MC & JOLLI FOODS ___

Storage
Method: Placed In Wooden Crate ___

Module 2B: RA 6969 (Hazardous Wastes Generator) page ____ of ____

Name of Plant:
Reference No:

ID: N/A Name: N/A ___

Transporter
Date: N/A ___

ID: N/A Name: N/A ___

Treater
Method: Date: N/A ___

ID: N/A Name: N/A ___

Disposal
Date: N/A Date: N/A ___

On-Site Self Inspection of Storage Area:

Corrective Action Taken
Date Conducted Premises/Area Inspected Findings & Observations
(if any)
Replace Containers &
04/15/2022 HW Storage Area Leaking Containers
Clean Area
05/15/2022 HW Storage Area Worn-out labels Replace Labels
06/15/2022 HW Storage Area No Findings Clean the Storage Area

Module 2B: RA 6969 (Hazardous Wastes Generator) page ____ of ____

Name of Plant:
Reference No:

C. Hazardous Wastes Treater/Recycler

HW Stored and/or Untreated as of End of Quarter:

Type of
Transport Storage Time Table
Wastes Date of
HW Number Permit/Date Valid until Quantity Container/ for
Generator Transport
of Issue # of Treatment
containers
N/A N/A N/A N/A N/A N/A N/A N/A

HW Treated and/or Recycled as of End of Quarter:

Type &
Type of
Transport Quantity of
Type of Wastes Date of Treatment or
HW Number Permit/Date Quantity Recycled or
Wastes Generator Transport Recycling
of Issue Treated
Process
Product
N/A N/A N/A N/A N/A N/A N/A N/A

Residual Wastes Generated from the Treatment and/or Recycling Operation:

Process by Type of
Type of which the Storage Disposal Time Table for
HW Number Quantity
Wastes Wastes is Container/ Option Disposal
Generated # of containers
N/A N/A N/A N/A N/A N/A N/A

Module 2C: RA 6969 (Hazardous Wastes Treater/Recycler) page ____ of ____

Name of Plant:
Reference No:

MODULE 3: P.D. 984 (Water Pollution)

Water Pollution Data

Domestic wastewater Process wastewater
7.0 2.0
(cubic meters/day) (cubic meters/day)
Cooling water Others: ___________
0 0
(cubic meters/day) (cubic meters/day)
Wash water, equipment Wash water, floor
10 0
(m3/day) (cubic meters/day)

Record of Cost of Treatment (Separate entries for separate facilities)

April 2022 May 2022 June 2022
Person employed, (# of
3 3 3
employees)
Person employed, (cost) 60,000 60,000 60,000
Cost of Chemicals used
5,000 5,000 5,000
by WTP
Utility Costs of WTP
800 800 800
(electricity & water)
Administrative and
2,400 2,400 2,400
Overhead Costs
Cost of operating in-
N/A N/A N/A
house laboratory
N/A N/A
New/Additional
N/A
Investments in WTP
(Description)

Cost of New/Add N/A N/A N/A

Investments

WTP Discharge Location

Outlet
Location of the Outlet Name of Receiving Water Body
Number
Timugan Creek
1 Left side of property, along J.P Rizal Street
draining to Manila Bay
2
3
4
5

Module 3: P.D. 984 (Water Pollution) page ____ of ____

Name of Plant:
Reference No:

Detailed Report of Wastewater Characteristics for Conventional Pollutants

Outlet No.

Effluent Oil & ________

BOD TSS Temp rise (name)
DATE Flow Rate Color pH Grease
(mg/L) (mg/L) (ºC)
(m3/day) (mg/L)
(unit)

Apr 1 12.0 48 50 2.5 2

Apr 2 12.0 48 50 2.5 2
Apr 3 12.0 48 50 2.5 2
Apr 4 12.0 48 50 2.5 2
Apr 5 12.0 48 50 2.5 2
Apr 6 12.0 48 50 2.5 2
Apr 8 12.0 48 50 2.5 2
Apr 9 12.0 48 50 2.5 2
Apr 10 12.0 48 50 2.5 2
Apr 11 12.0 48 50 2.5 2
Apr 12 12.0 48 50 2.5 2
Apr 13 12.0 48 50 2.5 2
Apr 15 12.0 48 50 2.5 2
Apr 16 12.0 48 50 2.5 2
Apr 17 12.0 48 50 2.5 2
Apr 18 12.0 48 50 2.5 2
Apr 19 12.0 48 50 2.5 2
Apr 20 12.0 48 50 2.5 2
Apr 22 12.0 48 50 2.5 2
Apr 23 12.0 48 50 2.5 2
Apr 24 12.0 48 50 2.5 2
Apr 25 12.0 48 50 2.5 2
Apr 26 12.0 48 50 2.5 2
Apr 27 12.0 48 50 2.5 2
Apr 29 12.0 48 50 2.5 2
Apr 30 12.0 48 50 2.5 2
Apr 31 12.0 48 50 2.5 2

Please fill-up/accomplish separate form/s for other outlet/s.

Detailed Report of Wastewater Characteristics for Other Pollutants

Module 3: P.D. 984 (Water Pollution) page ____ of ____

Name of Plant:
Reference No:

Outlet No.

Effluent Oil & ________

BOD TSS Temp rise (name)
DATE Flow Rate Color pH Grease
(mg/L) (mg/L) (ºC)
(m3/day) (mg/L)
(unit)

May 1 12.0 48 50 2.5 2

May 2 12.0 48 50 2.5 2
May 3 12.0 48 50 2.5 2
May 4 12.0 48 50 2.5 2
May 5 12.0 48 50 2.5 2
May 6 12.0 48 50 2.5 2
May 8 12.0 48 50 2.5 2
May 9 12.0 48 50 2.5 2
May 10 12.0 48 50 2.5 2
May 11 12.0 48 50 2.5 2
May 12 12.0 48 50 2.5 2
May 13 12.0 48 50 2.5 2
May 15 12.0 48 50 2.5 2
May 16 12.0 48 50 2.5 2
May 17 12.0 48 50 2.5 2
May 18 12.0 48 50 2.5 2
May 19 12.0 48 50 2.5 2
May 20 12.0 48 50 2.5 2
May 22 12.0 48 50 2.5 2
May 23 12.0 48 50 2.5 2
May 24 12.0 48 50 2.5 2
May 25 12.0 48 50 2.5 2
May 26 12.0 48 50 2.5 2
May 27 12.0 48 50 2.5 2
May 28 12.0 48 50 2.5 2

Please fill-up/accomplish separate form/s for other outlet/s.

Please use additional sheet/s if necessary.

Module 3: P.D. 984 (Water Pollution) page ____ of ____

Name of Plant:
Reference No:

Detailed Report of Wastewater Characteristics for Other Pollutants

Outlet No.

Effluent Oil & ________

BOD TSS Temp rise (name)
DATE Flow Rate Color pH Grease
(mg/L) (mg/L) (ºC)
(m3/day) (mg/L)
(unit)

Jun 1 12.0 48 50 2.5 2

Jun 2 12.0 48 50 2.5 2
Jun 3 12.0 48 50 2.5 2
Jun 4 12.0 48 50 2.5 2
Jun 5 12.0 48 50 2.5 2
Jun 6 12.0 48 50 2.5 2
Jun 8 12.0 48 50 2.5 2
Jun 9 12.0 48 50 2.5 2
Jun 10 12.0 48 50 2.5 2
Jun 11 12.0 48 50 2.5 2
Jun 12 12.0 48 50 2.5 2
Jun 13 12.0 48 50 2.5 2
Jun 15 12.0 48 50 2.5 2
Jun 16 12.0 48 50 2.5 2
Jun 17 12.0 48 50 2.5 2
Jun 18 12.0 48 50 2.5 2
Jun 19 12.0 48 50 2.5 2
Jun 20 12.0 48 50 2.5 2
Jun 22 12.0 48 50 2.5 2
Jun 23 12.0 48 50 2.5 2
Jun 24 12.0 48 50 2.5 2
Jun 25 12.0 48 50 2.5 2
Jun 26 12.0 48 50 2.5 2
Jun 27 12.0 48 50 2.5 2
Jun 28 12.0 48 50 2.5 2

Module 4: RA 8749 (Air Pollution) page ____ of ____

Name of Plant:
Reference No:

MODULE 4: R.A. 8749 (Air Pollution)

Summary of APSE/APCF
Process Equipment Location # of hrs of operations
1.
2.
3.
4.
Fuel Burning Quantity # of hrs of
Location Fuel Used
Equipment Consumed operations
1. Standby Genset Genset Room Diesel 120 L 11
2.
3.
4.
5.
6.
Pollution Control Facility Location # of hrs of operations
1.
2.
3.
4.

Cost of Treatment
Month 1 Month 2 Month 3
Cost of Person employed,
0 0 0
(salary)
Total Consumption of
0 0 0
Water (cubic meters)
Total Cost of chemicals
used (e.g., activated 0 0 0
carbon, KMnO4)
Total Consumption of
0 0 0
Electricity (KwH)
Administrative and
0 0 0
Overhead Costs
Cost of operating in-
0 0 0
house laboratory, if any
0 0
Improvement or
0
modification, if any.
(Description)

Module 4: RA 8749 (Air Pollution) page ____ of ____

Name of Plant:
Reference No:

Cost of improvement of 0 0 0
modification

Module 4: RA 8749 (Air Pollution) page ____ of ____

Name of Plant:
Reference No:

Detailed Report of Air Emission Characteristics

Description/Location
of PCF
________ ________ ________ ________
Flow Rate CO NOx Particulates (name) (name) (name) (name)
DATE
(Ncm/day) (mg/Ncm) (mg/Ncm) (mg/Ncm)
(mg/Ncm) (mg/Ncm) (mg/Ncm) (mg/Ncm)
N/A N/A N/A N/A N/A N/A N/A N/A N/A

Please fill-up/accomplish separate form/s for other PCF/s.

Please use additional sheet/s if necessary.

Module 4: RA 8749 (Air Pollution) page ____ of ____

Name of Plant:
Reference No:

MODULE 5: P.D. 1586

Ambient Air Quality Monitoring (if required as part of ECC conditions)
Description/Location
of Monitoring
Station
Noise ________ ________ ________ ________
CO NOx Particulates (name) (name) (name) (name)
DATE Level
(mg/Ncm) (mg/Ncm) (mg/Ncm)
(dB) (mg/Ncm) (mg/Ncm) (mg/Ncm) (mg/Ncm)
N/A N/A N/A N/A N/A N/A N/A N/A N/A

(Please accomplish one table per monitoring station.)

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

Description/Location
of Sampling Station
________ ________ ________ ________ ________ ________ ________ ________
(name) (name) (name) (name) (name) (name) (name) (name)
DATE
(unit) (unit) (unit) (unit) (unit) (unit) (unit) (unit)

(Please accomplish one table per sampling station.)

Module 5: P.D. 1586 (EIS System) page ____ of ____

Name of Plant:
Reference No:

Other ECC Conditions

Status of Compliance
ECC Condition/s Actions Taken
Yes No

1.
2.
3.
4.
5.
6.
Please use additional sheet/s if necessary.

Environmental Management Plan/Program

Status of
Enhancement/Mitigation Measures Implementation Actions Taken
Yes No

1.
2.
3.
4.
5.
6.
Please use additional sheet/s if necessary.

Solid Waste Characterization/Information:

Average Quantity of 400 kg Total Quantity of Solid 1200 kg
Solid Wastes Generated Wastes Generated this
per month Quarter
Average Quantity of 200 kg Total Quantity of Solid 600 kg
Solid Wastes Collected Wastes Collected this
per month Quarter
Entity in charge of Balatibat Hauling
Disposal Facility/SLF
collecting solid wastes Corp

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

Module 5: P.D. 1586 (EIS System) page ____ of ____

Name of Plant:
Reference No:

MODULE 6: OTHERS

Accidents & Emergency Records

Findings and
Date Area/Location Actions Taken Remarks
Observation
N/A N/A N/A N/A N/A

Personnel/Staff Training
# of Personnel
Date Conducted Course/Training Description
Trained
June 15, 2022 Solid Waste Management 10
Training

I hereby certify that the above information are true and correct.

Done this _________________________, in ________________________.

Name/Signature of PCO

Name/Signature of CEO

SUBSCRIBED AND SWORN before me, a Notary Public, this ________ day of
______________________, affiants exhibiting to me their Community Tax Receipts:

Name CTR No. Issued at Issued on

_____________________ _____________ _______________ ______________
_____________________ _____________ _______________ ______________

Module 5: P.D. 1586 (EIS System) page ____ of ____