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Republic of the Philippines

DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCES


ENVIRONMENTAL MANAGEMENT BUREAU
Office of the Regional Director
Region VI, Pepita Aquino Avenue, Iloilo City
Tel. No.: (033)3379801 * Telefax: (033)3369910 * Email:
embr6iyahoo.com

APPLICATION FOR DISCHARGE PERMIT


Application No: _______________
New
Renewal:

Permit No: _________________ Expiry Date: __ /__ /__


ECC No: ___________________

Fees Paid
Filing Fee
PD 186
Permit Fee
Wastewater Charge
Processing Fee

Amount (PhP)

Self Monitoring Report


Period Covered
SMR Submission Date

1 Qtr.

Hazardous Waste Generator ID No. ____________


O.R. No.

st

nd

Date

rd

2 Qtr.

th

3 Qtr.

4 Qtr.

INSTRUCTION: Fill in all appropriate spaces. Mark all appropriate boxes with an X. For items with numbers in
superscript, please refer to the Instructions and Directions in Accomplishing the Form under the Additional
Guidelines in Accomplishing the Form attached to this form.
NOTE:
I.

This Office will not accept an incomplete or incompletely filled-up applicable form.

General Information

Name of Establishment/Plant:

__________________________________________________________

Establishment Code ______________________ PSIC :

Description ____________________

Year Established: ________________ Capitalization: __________________ TIN: _________________________


Plant Address:
No. & Street Name: _____________________________
City or Municipality: _____________________________
Phone: _____________________________
E-mail: _____________________________
Name of PCO: _________________________________
Category of Accreditation: _______________________
Phone: _____________________________
E-mail: _____________________________
Legal Classification:

Single Proprietorship

Barangay: ____________________________________
Province: _____________________________________
Fax: _________________________________________
Accreditation No.: ______________________________
Accreditation Date: _____________________________
Fax: _________________________________________
Cell Phone: ____________________________________
Private Corporation

Partnership

Govt. Owned or Controlled Corporation Others: _______________


Ownership (%):

II.

III.

Private _____%
Local
_____%

Government _____%
Foreign
_____%

Employment and Operation Information


Number of Employees:
3
Production Workers/Service Providers : _____________________
Operating Time:
No. of hours/day
_____________________
No. of days/month
_____________________
No. of months/year
_____________________
Products/Service Information
Product/Service 1
5
Product Service Name
Unit
Rated Production Capacity
Annual Production
(projected or previous year)
Type of Process
Batch Continuous

NGO/NPO _____%

Administration : ______________________
______________________
______________________
______________________

Product/Service 2

Product/Service 3

Batch Continuous

Batch Continuous

IV.

V.

Information on non-industrial sectors such as restaurants and hotels, dwelling units, hospitals, medical,
dental and other health services, schools, and other similar establishments/ businesses
No. of customers or
Type of
Number of Days
Capacity (specific
No. of Employees
occupants or
Establishment
Operating per Year
unit __________ )
patients per year

Water Supply and Wastewater Generation


Average Water
3
Consumption (m )
Source of Water Supply
Daily
Annual

Estimated Flow (m /day)

Water Use/Sources of
Wastewater

Local Water District:


__________________
(Name of Water District)

Water
Consumed

Wastewater
Generated

Process
Washing/Cleaning
of
Process Equipment
Cooling
Domestic use such as
personal hygiene &
kitchen
Others (specify)

Deep Well
Surface Water (lake, river,
creek, etc.)
Others (specify)

Recycled/reused
for
irrigation and other
8
agricultural purposes
Total
Maximum Daily Flow
9
Rate

Total

Please submit a block diagram of the Water Balance.


VI.

QUALITY OF (ABSTRACTED) WATER SUPPLY


Sources of Water Supply

10

Average Priority Parameter Concentration (mg/L)


Heavy Metals
TSS
Oil & Grease
COD

BOD5

Local Water District:


__________________
(Name of Water District)
Deep Well
Surface Water (lake, river, creek,
etc.)
Others (specify)
11
Basis: Abstracted Water Quality
VII.

WATER POLLUTION INFORMATION


The Source ID and Outlet No. indicated below shall correspond with and match those indicated in the Sewer and
Drainage Plan and/or Drawing submitted with this application.
Source
12
ID

Discharge Outlet
No.

13

Location

Mode

Discharge
Days
(Days/Yr)

Ave. Flow
Rate
3
(m /day)

Priority Parameter Concentration (mg/L)


Outlet
No.

BOD
Influent

Effluent

TSS
Influent

Effluent

16

Oil & Grease

Effluent
Lipid/Total Mineral

Receiving Water Body


14

Name

14

Class

15

COD
Influent

Effluent

Heavy
Metal
______

Heavy
Metal
______

Effluent

Effluent

17

Outlet
No.

VIII.

BOD

Estimated Daily Average Net Waste Load (kg/day)


Heavy Metal
TSS
Oil & Grease
COD
______

FLOW MEASUREMENT INFORMATION


Outlet No.

Type of Flow Meter


Influent

IX.

WASTEWATER TREATMENT SYSTEM


Wastewater
Treatment Plant
(Name & Location)

Design Capacity
3
(m /day)

Heavy Metal
______

18

Effluent

19

Date Installed

Projected
Lifespan
(Years)

Treatment Cost (Pesos/Yr)


Capital Cost
(Depreciation)

O&M Cost

Components of Wastewater Treatment Plant/System and Treatment Efficiency (WTP-1)


Primary/Physical Treatment
Screening
Equalization
Grit Removal
Oil-water separation
Sedimentation (primary settling)
Others (specify) _____________________
20
Percent Reduction :
BOD _____ %
TSS _____ %
O&G ______%
Others (specify _______) _____ %
Chemical Treatment
pH adjustment
Disinfection
Flocculation/ Coagulation/ Precipitation
Oxidation/Reduction
Others (specify) _____________________
20
Percent Reduction :
BOD _____ %
TSS _____ %
O&G ______%
Others (specify _______) _____ %
Biological Treatment
Activated Sludge
Sequencing Batch Reactor Rotating Biological Contactor
Trickling Filter
Anaerobic Digestion
Uplflow Anaerobic Sludge Blanket (UASB) Reactor
Oxidation/Stabilization Pond
Others (specify) _____________________
20
Percent Reduction :
BOD _____ %
TSS _____ %
O&G ______%
Others (specify _______) _____ %
Components of Wastewater Treatment Plant/System and Treatment Efficiency (WTP-2)
Primary/Physical Treatment
Screening
Equalization
Grit Removal
Oil-water separation
Sedimentation (primary settling)
Others (specify) _____________________
20
Percent Reduction :
BOD _____ %
TSS _____ %
O&G ______%
Others (specify _______) _____ %
Chemical Treatment
pH adjustment
Disinfection
Flocculation/ Coagulation/ Precipitation
Oxidation/Reduction
Others (specify) _____________________
20
Percent Reduction :
BOD _____ %
TSS _____ %
O&G ______%
Others (specify _______) _____ %
Biological Treatment
Activated Sludge
Sequencing Batch Reactor Rotating Biological Contactor
Trickling Filter
Anaerobic Digestion
Upflow Anaerobic Sludge Blanket (UASB) Reactor
Oxidation/Stabilization Pond
Others (specify) _____________________
20
Percent Reduction :
BOD _____ %
TSS _____ %
O&G ______%
Others (specify _______) _____ %
Please provide additional sheets as necessary. For new application or when there is a process revision or
modification, please attach the Schematic Diagram of Treatment Process(es).

X.

Residual Management
Source

XI.

XII.

21

Type of Residual

Quantity

Disposal Method of Treatment


(Indicate disposal site, if applicable)

22

Wastewater Reuse for Irrigation and Other Agricultural Purposes


Certification
Ave. Discharge
Discharge
Type of Wastewater Reuse
3
from DA (No.)
Rate (m /day)
Days/Year

Vicinity Map

Site of Wastewater Reuse

23

I hereby certify that the above information is true and correct to the best of my knowledge. Done this ____ day of
___________ of 20 ___.

____________________________ ___
Signature over Printed Name of PCO

______________________________________
24
Signature of Printed Name of Managing Head

SUBSCRIBED AND SWORN to before a Notary Public. This ___ day of _______ of 20 ___. Affiant exhibiting to me
his/her Community Tax Certificate as follows:
Name

Community Tax
Receipt No.

Place Issued

Date Issued

NOTARY PUBLIC
Doc. No. : _____
Page No. : _____
Book No. : _____
Series of _____