Republic of the Philippines DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCES ENVIRONMENTAL MANAGEMENT BUREAU

Office of the Regional Director Region IX, Western Mindanao

2/F Pastoriza Bldg., Datoc St., Gatas District, Pagadian City (062) 215-4137

Application for Discharge Permit New Renewal Expiry Date TIN Application No. INSTRUCTION: Fill in all appropriate white spaces. Mark all appropriate boxes with an “X”. NOTE: Failure to complete this form may be sufficient ground for disapproval of the permit application. GENERAL INFORMATION Name of Establishment/Plant Est. Code Year Est. Plant Address: No. & Street Name Barangay City or Municipality Province Type of Industry Name of PCO Accreditation Date Tel. No. & Cel. No. Fax No. Legal Classification Proprietorship Private Corporation Multinational Others, specify Ownership Terms (%) Private % Foreign % Government % EMPLOYMENT AND OPERATION INFORMATION Total Employment (number of workers) in the factory: Production Non-Production Production Time: Number of Hours/day Number of days/month Number of months/year SOURCES OF WATER SUPPLY AND WASTEWATER GENERATION

Sources of Water Supply

Monthly Ave. Vol. (m3)

Daily Ave. Vol. (m3)

Generating Process

Estimated Flow

(m3) MWSS (Please attach water bills)

Process Water

Local Water District (Please attach water bills)

Washing/Cleaning of Process Water

Deep wells

Cooling

Surface waterbodies, river, creek, etc.

Domestic

Others

Recycled/Reuse

Others (drinking water, gardening, evaporation, leaks, product component, etc.)

Total Water Consumption

Total Volume of Discharge Wastewater

Dwelling Units Information (hotels, condominium, restaurants, malls, etc) Total Floor Area No. of Bedrooms No. of Guest/Year Total Area for Dwelling Unit (m2) No. of Restaurants/Dining Unit

PRODUCTION INFORMATION Product 1 Product 2 Product 3 Product Name

Actual Production

Actual Production in the Previous Year

Type of Process

Batch Continuous

Batch Continuous

Batch Continuous

Note: **Please use generic product name, not in brand names, in metric tons of product, carbonated drinks and beer (m3) Except for the following substances: hog raising (heads), slaughtering/preserving Water Pollution Information

Outlet Number

Location & Distribution of

Outlet

Name of the Receiving body if not discharging in

the lake

Estimated Ave. BOD/TSS conc.

(mg/L)

Estimated Ave. Rate of Discharge

(m3/day)

Estimated BOD/TSS (kg/day)

Average Load

1 2 3

Total

Name of Laboratory Performing Analysis: Address of Laboratory: Date of Sampling: Date of Analysis: Method of Sampling: Vicinity Map (The map should show relative location of the establishment with respect to existing structures, landmarks, rivers, lakes and other water bodies, etc.. Use scale to fit into the frame below.) Fixed Fee Official Receipt Number:__________________________________ Date of Issue:___________________ I hereby certify that the above information are true and correct to the best of my knowledge. Done this ___ day of ____________ of 20____. ____ ______________________________________ ______ _ ________________________ Name and Signature of Pollution Control Officer Chief Executive Officer SUBSCRIBED AND SWORN to before a Notary Public. This ______________ day of ________________. Affiant exhibiting to me his/her Community Tax Receipt No. _________________________________ issued at ____________________ on ________________________. _________________________________ Notary Public Doc. No.________ Page No.________ Book No.________ Series of ________

REQUIREMENTS FOR APPLICATION FOR A WASTEWATER DISCHARGE PERMIT FOR NEW APPLICATION: Name of Establishment: Address:

A) Engineer’s Report 1. Vicinity Map 2. Nature of Project or Business 3. Production Capacity

Quantity or Volume and Generic Name/s of Product/s

4. Nature and character of the applicant’s wastewater and its physical and chemical composition 5. Total daily volume of discharge of raw wastewater

6. Treatment process and estimated treatment efficiency

7. Total daily volume of water consumption and discharge of final treated wastewater or effluent

8. The name of receiving body of water and its official water classification and in case of land discharge,

the nearest receiving body of water and its official water classification

9. Information on flow measurement equipment and procedure

10. Pollution prevention/Environmental System plan or program

11. DENR ID Number as hazardous waste generator (if applicable)

12. Statement of the cost incurred in the installation and maintenance of wastewater treatment facility, if any

13. Quality and quantity of abstracted water

14. Copy of ECC or CNC (if applicable)