Department of Environment and Natural Resources

Environmental Management Bureau

G E N E R A L I N F O R MAT I O N ! E E T
Name of the
Establishment/Facility
Establishment/Facility
Address
(NOT the company of head
office)
Street # & Street Name: ___
Baranay: !ity/"#nicipality: ___
$ro%ince:
Name of
&'ner/!ompany
Address
(if address is not the same as
pre%io#s address)
Street # & Street Name: ___
Baranay: !ity/"#nicipality: ___
$ro%ince:
$hone N#mber Fa( N#mber
e)mail address
*ype of B#siness/
+nd#stry !lassification
$hilippine Standard +nd#stry !lassification !ode No, ___
$hilippine Standard +nd#stry -escriptor: ___
___
.esponsible &fficer/s:
!E&/$resident, ___
*el #: Fa( #: ___
e)mail address: ___
$lant "anaer: ___
*el #: Fa( #: ___
e)mail address: ___
$oll#tion !ontrol
&fficer
Name, ___
*el #: Fa( #: ___
e)mail address: ___
/eal !lassification
sinle proprietorship partnership
pri%ate domestic corporation o%ernment corporation
"#lti)national ___
We hereby certify that the above information are true and correct.

Name/Sinat#re of !E&/$resident Name/Sinat#re of $!&
Reference No"
(to be filled #p by -EN. only)
Name of Plant:

Department of Environment and Natural Resources
Environmental Management Bureau
# $ A R T E R L% E L F & MO N I T O R I N G R E ' O R T
MOD$LE (" GENERAL INFORMATION
Name of the $lant
$lease pro%ide the necessary re%ised0 corrected or #pdated information not contained in yo#r General
Information Sheet
(#se additional sheet/s if necessary)
DENR 'ermits)Licenses)*learances
En%ironmental
/a's
$ermits -ate of +ss#e E(piry -ate
$,-, 123
A/! No,
$& No,
$- 4526
E!! 4
E!! 7
E!! 8
.A 6161
-EN.
.eistry +-
!!& .eistry
+mporter
!learance No
$ermit to
*ransport
.A 2931
A/! No,
$& No,
Module 1: General Information page ____ of ____
Reference No"
Name of Plant:

Operation
&peratin ho#rs/day &peratin days/'ee: # of shift/day
A%erae
"a(im#m
Operation)'roduction)*apacit+"
A%erae -aily $rod#ction
&#tp#t
*otal &#tp#t this ;#arter
*otal <ater !ons#mption
this ;#arter (c#bic
meters)
*otal Electric
!ons#mption this ;#arter
(='>)
$lease #se additional sheet/s if necessary
Module 1: General Information page ____ of ____
Reference No"
Name of Plant:

MOD$LE ," RA -.-.
A/ **O Report 0please accomplis1 t1is section for eac1 c1emical)su2stance3
!ommon Name/+?$A!/!AS +nde( Name, ___
!AS No,: ___
*rade Name: ___
For importers only:
;#antity
.e@#ested
+mport
!learance
No,
-ate of
Arri%al
;#antity
.ecei%ed
A
$ort of Entry
!o#ntry of
&riin
!o#ntry of
"an#fact#re
*otal ;#antity .e@#ested
(ann#al)
*otal ;#antity .ecei%ed
(ann#al)
A attach copy/s of Bill of /adin
For distrib#tors (importers/non)importers)
Name of !lient /icense No, ;#antity -ate of -istrib#tion
*otal ;#antity -istrib#ted
For non)importer #sers:
Name of -istrib#tor ;#antity -ate of $#rchase
*otal ;#antity $#rchased from -istrib#tor
For prod#cers
Module 2B: RA 6969 (Hazardous astes Generator! page ____ of ____
Reference No"
Name of Plant:

A%erae -aily $rod#ction
&#tp#t
*otal &#tp#t this ;#arter
;#antity of Stoc:
+n%entory (Start of
;#arter)
;#antity of Stoc:
+n%entory (End of
;#arter)
Name of B#yer ;#antity -ate of $#rchase
*otal ;#antity Sold
$sed in 'roduction (please fill #p only if chemical/s#bstance is not main prod#ct)
A%erae -aily $rod#ction
&#tp#t
*otal &#tp#t this ;#arter
A%erae ;#antity ?sed
per month
*otal ;#antity ?sed this
;#arter
-escribe any chanes in $rod#ction/$rocess/&perations:
toc4 Inventor+)5aste *1emical Generated"
A%erae ;#antity of
<aste !hemical
Benerated per month
*otal ;#antity of <aste
!hemical Benerated this
;#arter
;#antity of Stoc:
+n%entory (Start of
;#arter)
;#antity of Stoc:
+n%entory (End of
;#arter)
Ot1er Information"
"anner of handlin
haCardo#s 'astes
storae on)site *reatment on)site
storae off)site *reatment off)site
!hanes in Safety
"anaement System
Des (please attach copy of re%ised plan)
No
!hemical S#bstit#te
$lan
Des (please attach copy if not s#bmitted/incl#ded in pre%io#s report/s or had been re%ised)
No
B/ !a6ardous 5astes Generator
Module 2B: RA 6969 (Hazardous astes Generator! page ____ of ____
Reference No"
Name of Plant:

!5 Generation"
>< No, >< !lass >< Nat#re
><
!atalo#in
.emainin >< from
$re%io#s .eport
>< Benerated
;#antity ?nit ;#antity ?nit
5aste torage7 Treatment and Disposal"($lease fill)#p one table per ><)
>< -etails
>< No0: ___
;ty of >< *reated: ?nit: ___
*S- /ocation: ___
Storae
Name: ___
"ethod: ___
*ransporter
+-: Name: ___
-ate: ___
*reater
+-: Name: ___
"ethod: -ate: ___
-isposal
+-: Name: ___
-ate: -ate: ___
>< -etails
>< No0: ___
;ty of >< *reated: ?nit: ___
*S- /ocation: ___
Storae
Name: ___
"ethod: ___
*ransporter
+-: Name: ___
-ate: ___
*reater
+-: Name: ___
"ethod: -ate: ___
-isposal
+-: Name: ___
-ate: -ate: ___
On&ite elf Inspection of torage Area"
Module 2B: RA 6969 (Hazardous astes Generator! page ____ of ____
Reference No"
Name of Plant:

-ate !ond#cted $remises/Area +nspected Findins & &bser%ations
!orrecti%e Action *a:en
(if any)
Module 2B: RA 6969 (Hazardous astes Generator! page ____ of ____
Reference No"
Name of Plant:

*/ !a6ardous 5astes Treater)Rec+cler
!5 tored and)or $ntreated as of End of #uarter"
>< N#mber
<astes
Benerator
-ate of
*ransport
*ransport
$ermit/-ate
of +ss#e
Ealid #ntil ;#antity
*ype of
Storae
!ontainer/
# of
containers
*ime *able
for
*reatment
!5 Treated and)or Rec+cled as of End of #uarter"
*ype of
<astes
>< N#mber
<astes
Benerator
-ate of
*ransport
*ransport
$ermit/-ate
of +ss#e
;#antity
*ype of
*reatment or
.ecyclin
$rocess
*ype &
;#antity of
.ecycled or
*reated
$rod#ct
Residual 5astes Generated from t1e Treatment and)or Rec+cling Operation"
*ype of <astes >< N#mber
$rocess by
'hich the
<astes is
Benerated
;#antity
*ype of
Storae
!ontainer/
# of containers
-isposal
&ption
*ime *able for
-isposal
Module 2": RA 6969 (Hazardous astes #reater$Re%&%ler! page ____ of ____
Reference No"
Name of Plant:

MOD$LE 8" '/D/ .9: 05ater 'ollution3
5ater 'ollution Data
-omestic 'aste'ater
(c#bic meters/day)
$rocess 'aste'ater
(c#bic meters/day)
!oolin 'ater
(c#bic meters/day)
&thers: ___________
(c#bic meters/day)
<ash 'ater0 e@#ipment
(m
8
/day)
<ash 'ater0 floor
(c#bic meters/day)
Record of *ost of Treatment 0eparate entries for separate facilities3
"onth 4 "onth 7 "onth 8
$erson employed0 (# of
employees)
$erson employed0 (cost)
!ost of !hemicals #sed
by <*$
?tility !osts of <*$
(electricity & 'ater)
Administrati%e and
&%erhead !osts
!ost of operatin in)
ho#se laboratory
Ne'/Additional
+n%estments in <*$
(-escription)
!ost of Ne'/Add
+n%estments
5T' Disc1arge Location
&#tlet
N#mber
/ocation of the &#tlet Name of .ecei%in <ater Body
4
7
8
3
5
Module ': P()( 9*+ (ater Pollution! page ____ of ____
Reference No"
Name of Plant:

Detailed Report of 5aste;ater *1aracteristics for *onventional 'ollutants
&#tlet No,
-A*E
Effl#ent
Flo' .ate
(m
8
/day)
B&-
(m//)
*SS
(m//)
!olor p>
&il &
Brease
(m//)
*emp rise
(F!)
________
(name)
(#nit)
'lease fill&up)accomplis1 separate form)s for ot1er outlet)s/
Module ': P()( 9*+ (ater Pollution! page ____ of ____
Reference No"
Name of Plant:

Detailed Report of 5aste;ater *1aracteristics for Ot1er 'ollutants
&#tlet No,
-A*E
Effl#ent
Flo' .ate
(m
8
/day)
________
(name)
(#nit)
________
(name)
(#nit)
________
(name)
(#nit)
________
(name)
(#nit)
________
(name)
(#nit)
________
(name)
(#nit)
________
(name)
(#nit)
'lease fill&up)accomplis1 separate form)s for ot1er outlet)s/
'lease use additional s1eet)s if necessar+/
Module ': P()( 9*+ (ater Pollution! page ____ of ____
Reference No"
Name of Plant:

MOD$LE :" R/A/ 9<:. 0Air 'ollution3
ummar+ of A'E)A'*F
$rocess E@#ipment /ocation # of hrs of operations
4,
7,
8,
3,
F#el B#rnin
E@#ipment
/ocation F#el ?sed
;#antity
!ons#med
# of hrs of
operations
4,
7,
8,
3,
5,
6,
$oll#tion !ontrol Facility /ocation # of hrs of operations
4,
7,
8,
3,
*ost of Treatment
"onth 4 "onth 7 "onth 8
!ost of $erson employed0
(salary)
*otal !ons#mption of
<ater (c#bic meters)
*otal !ost of chemicals
#sed (e,,0 acti%ated
carbon0 ="n&3)
*otal !ons#mption of
Electricity (='>)
Administrati%e and
&%erhead !osts
!ost of operatin in)
ho#se laboratory0 if any
+mpro%ement or
modification0 if any,
(-escription)
!ost of impro%ement of
modification
Module +: RA *,+9 (Air Pollution! page ____ of ____
Reference No"
Name of Plant:

Detailed Report of Air Emission *1aracteristics
-escription//ocation
of $!F
-A*E
Flo' .ate
(Ncm/day)
!&
(m/Ncm)
N&(
(m/Ncm)
$artic#lates
(m/Ncm)
________
(name)
(m/Ncm)
________
(name)
(m/Ncm)
________
(name)
(m/Ncm)
________
(name)
(m/Ncm)
'lease fill&up)accomplis1 separate form)s for ot1er '*F)s/
'lease use additional s1eet)s if necessar+/
Module +: RA *,+9 (Air Pollution! page ____ of ____
Reference No"
Name of Plant:

MOD$LE =" '/D/ (=9-
Am2ient Air #ualit+ Monitoring 0if re>uired as part of E** conditions3
-escription//ocation
of "onitorin
Station
-A*E
Noise
/e%el
(dB)
!&
(m/Ncm
)
N&(
(m/Ncm
)
$artic#lates
(m/Ncm)
________
(name)
(m/Ncm
)
________
(name)
(m/Ncm
)
________
(name)
(m/Ncm
)
________
(name)
(m/Ncm)
($lease accomplish one table per monitorin station,)
Am2ient 5ater #ualit+ Monitoring 0if re>uired as part of E** conditions3
-escription//ocation
of Samplin Station
-A*E
________
(name)
(#nit)
________
(name)
(#nit)
________
(name)
(#nit)
________
(name)
(#nit)
________
(name)
(#nit)
________
(name)
(#nit)
________
(name)
(#nit)
________
(name)
(#nit)
($lease accomplish one table per samplin station,)
Module -: P()( 1-*6 (.I/ /&stem! page ____ of ____
Reference No"
Name of Plant:

Ot1er E** *onditions
E!! !ondition/s
Stat#s of !ompliance
Actions *a:en
Des No
4,
7,
8,
3,
5,
6,
'lease use additional s1eet)s if necessar+/
Environmental Management 'lan)'rogram
Enhancement/"itiation "eas#res
Stat#s of
+mplementation
Actions *a:en
Des No
4,
7,
8,
3,
5,
6,
'lease use additional s1eet)s if necessar+/
olid 5aste *1aracteri6ation)Information"
A%erae ;#antity of
Solid <astes Benerated
per month
*otal ;#antity of Solid
<astes Benerated this
;#arter
A%erae ;#antity of
Solid <astes !ollected
per month
*otal ;#antity of Solid
<astes !ollected this
;#arter
Entity in chare of
collectin solid 'astes
Brief -escription of
Solid <aste
"anaement $lan (e,,0
'aste red#ction0
sereation0 recyclin)
Module -: P()( 1-*6 (.I/ /&stem! page ____ of ____
Reference No"
Name of Plant:

MOD$LE -" OT!ER
Accidents ? Emergenc+ Records
-ate Area//ocation
Findins and
&bser%ation
Actions *a:en .emar:s
'ersonnel)taff Training
-ate !ond#cted !o#rse/*rainin -escription
# of $ersonnel
*rained
I hereby certify that the above information are true and correct.
-one this _________________________0 in ________________________,

Name/Sinat#re of $!&

Name/Sinat#re of !E&
S?BS!.+BE- AN- S<&.N before me0 a Notary $#blic0 this ________ day of
______________________0 affiants e(hibitin to me their !omm#nity *a( .eceipts:
Name !*. No, +ss#ed at +ss#ed on
_____________________ _____________ _______________ ______________
_____________________ _____________ _______________ ______________
Module -: P()( 1-*6 (.I/ /&stem! page ____ of ____
Reference No"