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f o r _ _ _ Q u a r t e r, Yea r _ _ _ _
MODULE 1:
GENERAL INFORMATION
Name of the
Establishment /
Facility
Establishment /
Facility Address
Fax Number
Phone Number
e-mail address
CEO/President. __________________________________________________
Tel. No.: ______________________ Fax No.: _______________________
Responsible Officer/s:
Pollution Control
Officer
Legal Classification
Single Proprietorship
Private Domestic Corporation
Multi-national
Partnership
Government Corporation
Others__________________________
Permits/Licenses/Clearances
Environmental
Laws
PD 1586/ SBMA
EIS System
Permits
Date of Issue
Expiry Date
Date of Issue
Expiry Date
ECC
ECC Amendment 1
Environmental
Permits
Laws
PD 1586/ SBMA
EIS System
ECC Amendment 2
ECC Amendment 3
RA 8749
PTO No.
RA 9275
DP No.
DENR Registry ID
CCO Registry
RA 6969
Importer Clearance
No.
Permit to Transport
Operation
Operating hours/day
Operating days/week
# of shift/day
Average
Maximum
Operation/Production/Capacity:
Average Daily
Production Output
Total Water
Consumption this
Quarter (cubic meters)
Total Electric
Consumption this
Quarter (KwH)
RA 6969
Chemicals Used
Name
Common Name
CAS No.
Origin
Volume (Kg)/month
Average Quantity of
Waste Chemical
Generated per month
Total Quantity of
Waste Chemical
Generated this
Quarter
Quantity of Stock
Inventory (Start of
Quarter)
Quantity of Stock
Inventory (End of
Quarter)
Other Information:
Manner of handling
hazardous wastes
storage on-site
Treatment on-site
storage off-site
Treatment off-site
Changes in Safety
Management System
Chemical Substitute
Plan
Yes (please attach copy if not submitted/included in previous report/s or had been
revised)
No
No
B.
HW Generation:
HW
No.
HW Class
HW
Nature
HW
Cataloguing
Remaining HW from
previous report
Quantity
Unit
HW Generated
Quantity
Waste Storage, Treatment and Disposal: (please fill-up one table per HW)
HW Details
HW No.: _____________________________
Qty. of HW treated: _____________________
Unit __________________
Unit
Storage
Name: _____________________________________
Method: __________________________________
ID ______________________
Transporter
Date:_______________________
Name: _____________________________________
Date:_________________________________________________
ID ______________________
Treater
Name: _____________________________________
Method: __________________________________
ID ______________________
Disposal
Date:_______________________
Name: _____________________________________
Method: __________________________________
Date:_______________________
MODULE 3:
Premises / Area
Inspected
_________(cu. m./day)
Process wastewater
_________(cu. m./day)
Others:
_________(cu. m./day)
__ yes
___ no
Septic Tank
__ yes
___ no
Grease Trap
__ yes
___ no
_________(cu. m./day)
_________(cu. m./day)
_________(cu. m./day)
Oil-water separator
__ yes
___ no
Month 2
Month 3
Person employed, (# of
employees)
Person employed,
(cost)
Cost of Chemicals
used by WTP
Utility Costs of WTP
(electricity & water)
Administrative and
Overhead Costs
Cost of operating inhouse laboratory
New/Additional
Investments in WTP
(Description)
Cost of New/Add
Investments
1
2
3
BOD
TSS
(mg/L)
(mg/L)
pH
Standard
(Please fill-up/accomplish separate form/s for other outlet/s.)
MODULE 4:
Summary of APSE/APCF
Process Equipment
# of hrs of operations
1.
2.
3.
Fuel Burning Equipment
Quantity
Consumed
Fuel Used
# of hrs of
operations
1.
2.
Pollution Control Facility/Device
# of hrs of operations
1.
2.
3.
Cost of Treatment
Month 1
Cost of Person
employed, (salary)
Total Consumption of
Water (cubic meters)
Total Cost of
chemicals used (e.g.,
activated carbon,
KMnO4)
Total Consumption of
Electricity (KwH)
Administrative and
Overhead Costs
Cost of operating inhouse laboratory, if
any
Month 2
Month 3
Improvement or
modification, if any.
(Description)
Cost of improvement
of modification
DATE
Flow
Rate
(Ncm/
day)
CO
(mg/Ncm)
NOx
(mg/Ncm)
Particulate
s
_______
(mg/Ncm)
(mg/Ncm)
(name)
_______
(name)
(mg/Ncm
)
_______
_______
(name)
(name)
(mg/Ncm)
(mg/Ncm)
Standard
MODULE 5:
Noise
Level
(dB)
CO
NOx
Particulates
_______
_______
_______
_______
(mg/Ncm)
(mg/
Ncm)
(mg/Ncm)
(name)
(name)
(name)
(name)
(mg/Ncm)
(mg/Ncm)
(mg/Ncm)
(mg/Ncm)
Standard
(Please accomplish one table per monitoring station.)
Ambient Water Quality Monitoring (if required as part of ECC conditions)
Description/Location
of Sampling Station
DATE
_______
_______
_______
_______
_______
_______
_______
_______
(name)
(name)
(name)
(name)
(name)
(name)
(name)
(name)
(unit)
(unit)
(unit)
(unit)
(unit)
(unit)
(unit)
(unit)
Standard
(Please accomplish one table per sampling station.)
Other ECC Conditions
ECC Condition/s
Status of Compliance
Yes
No
Actions Taken
1.
2.
3.
4.
5.
(Please accomplish one table per sampling station.)
Environmental Management Plan/Program
Enhancement/Mitigation Measures
Status of
Implementation
Yes
No
1.
2.
3.
4.
5.
(Please use additional sheet/s if necessary).
Total Quantity of
Solid Wastes
Generated this
Quarter (Kg)
Actions Taken
Average Quantity of
Solid Wastes Collected
per month (Kg)
Total Quantity of
Solid Wastes
Collected this
Quarter (Kg)
Entity in charge of
collecting solid wastes
Brief Description of
Solid Waste
Management Plan (e.g.
waste reduction,
segregation, recycling)
MODULE 6:
OTHERS
Area/Location
Findings and
Observation
Actions Taken
Remarks
Personnel/Staff Training
Date Conducted
Course/Training Description
# of Personnel Trained
I hereby certify that the above information are true and correct.
Name/Signature of CEO
Name/Signature of PCO