Republic of the Philippines

Department of Environment and Natural Resources

ENVIRONMENTAL MANAGEMENT BUREAU
Regional Office No. V
Legazpi City

APPLICATION FOR PERMIT TO OPERATE

For Air Pollution Source and Control Installations
(IMPORTANT: Read the INSTRUCTIONS at the back hereof before accomplishing the form)

TYPE : New Renewal Change of Ownership

1. Name and Position of Applicant :

2. Name of Firm/Establishment :
3. Office Address : Tel. No.(s) :
4. Plant Location : Tel. No.(s) :
5. Capitalization/Authorized : Paid up :
6. Name of Accredited Pollution Control Officer :
Tel. No.(s) :

7. Nature of Business :

8. Geographical Coordinates: Longitude ________________ Latitude __________________

9. List of Air Pollution Source Equipment (APSE) Process(es) and corresponding Air Pollution
Control Facility(ies) (APCF) covered by the permit application. (Use additional sheet if
necessary).

Description Date

(e.g. 500Hp boiler/scrubber, 10-ton capacity APSE APCF

reverbetory baghouse, etc.)

a.
b.
c.
d.
e.
f.
10. Maintenance and Operating of APCEs : a. Power :
b b. Labor :

c c. Replacement Parts :

d d. Others (Specify) :

e
11. For new permit application, total cost of all APCEs (including construction cost) covered by
the same: ____________
12. Have you submitted all the required SUPPORTING DOCUMENTS listed at the back?
[ ] Yes [ ] Partially [ ] No

If YES, submit only this application form duly accomplished and indicate in the
transmittal letter that no modification(s) had been made previously submitted
documents.

If PARTIALLY or NO, submit all lacking documents respectively. Indicate the partially
submitted in the transmittal letter. (Refer to Item No. 2 of INSTRUCTION at the back).

CERTIFIED CORRECT:
 Signature Over Printed Name

Filing Fee O.R. Number Date

Permit Fee O.R. Number Date
P.D. 1856 O.R. Number Date
PAB Res 10A O.R. Number Date
INSTRUCTION FOR FILING APPLICATION

1. This form shall be fully accomplished and notarized and the required
supporting documents shall be submitted completely, otherwise the
application will be returned.

2. This form and the required supporting documents shall be submitted in duplicate
copies of applicant plant/establishment is located in Luzon and in triplicate copies if
located in Visayas and Mindanao and shall be accompanied by a letter of transmittal
addressed to the Regional Director, EMB V.

SUPPORTING DOCUMENTS
NEW
1. Engineers Report duly signed by a registered Engineer covering the ff:
a. Process of the plant/establishment/firm covering its operations and
descriptions (to include Company Profile)
b. Process Flow of APSE/APCF (Schematic Flow Diagram of all processes)
c. List of Air Pollution Source Equipment (APSE) & its corresponding Air
Pollution Control Facility (APCF) [including its capacity and usage]
d. Specific Fuel Consumption (L/hr) (e.g. for generator set and boilers) or
Raw Material Capacity ( Ex. Feedmills/Ricemills/Manufacturing Plants/etc.)
e. Plant / Machinery Layout
(Plan and Specification of APSE/APCF (standard size of 50cm x 90 cm)
duly certified by PME, RChE, RME or any appropriate engineer depending
on the nature of the construction, operation or activity to be permitted)
f. Colored pictures of APSE/APCF
g. Comprehensive Environmental Management Plan (EMP)
2. Vicinity Map/Sketch Map
3. Accredited Pollution Control Officer (PCO) as per DAO 2014-02
4. Photocopy of the ff:
a. Environmental Compliance Certificate (ECC)- if covered or Certificate of
Non-Coverage (CNC) (if applicable)
b. Barangay Certification of No-Complaint against Proponents
Business/Operation
c. Zoning Certificate or Location Clearance
d. DTI Business Registration or SEC Registration Certificate or Cooperative
Registration Certificate
e. Latest Mayors Business Permit/Brgy. Business Permit
5. Emission Test Result
6. Dispersion Modelling Report
7. Others documents that may be required by the Bureau

RENEWAL
1. Photocopy of ECC / CNC (if applicable)
2. Latest Self-Monitoring Report (SMR) Submitted (photocopy/original forms)
3. Accredited Pollution Control Officer (PCO) per DAO 2014-02
4. Photocopy of Latest Permit to Operate (POA) issued
5. Inspection Report (if applicable)
6. Emission Test Result/Report APSEs rated capacities 300 KW and above; 50 HP
and above; & 10 tonnes and above per year emission of an air pollutant
regulated under CAA
7. Others documents that may be required by the Bureau
 SUBSCRIBED AND SWORN TO before me this ________________________
day of _______________________________ 201_, _________________________.