Republic of the Philippines

Department of Environment and Natural Resources

ENVIRONMENTAL MANAGEMENT BUREAU
Region XI
Door 2, Felbets Bldg., Lanang, Davao City
Tel No. 234-0061./ Fax No. 233-0809

APPLICATION FORM FOR WASTEWATER DISCHARGE PERMIT

New ECC/CNC Issued:
Renewal Expiry Date TIN:
Application No.

INSTRUCTION: Fill in all appropriate 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:
Tel. No. & Cel. No.:
Legal Classification
Ownership Terms (%)
Certificate of Accreditation No:
Accreditation Date:
Fax No.:
Proprietorship
Private Corporation Others: Specify___________________________
Multinational
Private: ____% PO: ______________% Gov’t.: ____________%

Employment and Operation Information

Total Employment (number of workers) in the factor
Production Non-Production
Production Time: No. of Hrs/ day:________ No. of days/ month: _____ No. of mo./ yr.: _________

Sources of Water Supply and Wastewater Generation

Sources of Water Supply Monthly Daily Ave. Generating Process Estimated Flow
Ave. Vol. Vol. (m3/day)
(m3) (m3)
DCWD (please attach water Process Wastewater
bills)
Local Water District (please Washing / Cleaning of Process
attach water bills) Equipment
Deep Well Cooling
Surface Water (lake, river, Domestic
creek, etc.)
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 :_________m2 No. of Bedrooms: ___________ No. of Guests/ yr.:___________

Total Floor Area for Dwelling Unit No. of Restaurants/ Dining Unit

Product Information
Product 1 Product 2 Product 3
Product Name
Actual Production
Capacity
Actual Production in
the Previous Year
Type of Process Batch [ ] Continuous [ ] Batch [ ] Continuous [ ] Batch [ ] Continuous [ ]
Note: xx Please use generic product name, not in brand names, in metric tons of products except for the following
substances: hog raising (heads), carbonated drinks and beers (m 3), slaughtering/ preserving meat/ ton LWK,
electroplating (m2)
Water Pollution Information
Number of the Estimated Estimated Estimated
Outlet Location & Distribution of the Receiving Body if Average BOD Average rate Ave. BOD
Number Outlet NOT Discharging Concentration of Discharge Load
Directly in the Lake (mg/L) (m3/ day) (kg/ day)

Total

Name of laboratory performing analysis: _________________________________________

Address of laboratory: ______________________________________________________________________
Date of Sampling (mm/dd/yy): ___________________ Date of Analysis (mm/dd/yy): ____________________

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)

Permit Fee Official Receipt Number:

I hereby certify that the above information are true to the best of my knowledge. Done this _______ day
of ___________________month ____________year.

___________________________ ____________________________________
Pollution Control Officer Chief Executive Officer

SUBSCRIBED AND SWORN, to before me this ______ day of __________, in the City of Davao, Philippines, I
hereby certify that I have personally examined the affiant Community Tax Receipt No. ________________,
issued on _______________, at ____________, and that I am convinced that he voluntarily executed the
foregoing instrument..
 INSTRUCTIONS

APPLICATION FORM FOR A “WASTEWATER DISCHARGE PERMIT”

1. Fully accomplish this form and complete all the supporting documents indicated hereunder. Submit all
documents in two (2) copies to Pollution Control Division for its pre-evaluation.
2. Pay to the Cahier’s unit the corresponding amount indicated in the Permit Fee Payment form and
present the official receipt to the Pollution Control Division for the recording and notation of your
application.
3. File your application to the Records Unit and ask for the receiving copy of your application.
4. Your application shall be acted upon within thirty (30) working days and you shall be informed of our
action accordingly.

NOTE: INCOMPLETE APPLICATION WILL NOT BE ACCEPTED

Types of Applications Documents Required
New 1, 2, 4, 7
Renewal/Upgrade/Rehabilitation 2, 3, 4, 5, 6, 7

1. Engineer’s Report, signed by a registered chemical or sanitary engineer or Pollution Control

Officer and concurred by the Managing Head, containing the following information:

i) vicinity map identifying the street address, location or plant premise;

ii) the nature of project or business;
iii) production capacity; quantity or volume and the generic name(s) of product(s);
iv) the nature and character of the applicant’s wastewater and its physical and chemical
composition;
v) total daily volume of discharge of raw wastewater;
vi) treatment process and estimated efficiency;
vii) the total daily volume of water consumption and discharge of final treated wastewater or
effluent;
viii) 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.
ix) information on flow measurement equipment and procedure;
x) Pollution prevention/ Environmental Management System plan or program.
xi) DENR ID Number as hazardous waste generator (if applicable)
xii) statement of the cost incurred in the installation and maintenance of wastewater treatment
facility, if any.
xiii) quality and quantity of abstracted water
xiv) copy of the Environmental Compliance Certificate (ECC) from the Department or Certificate
of Non-Coverage (CNC), as applicable.

2. A copy of the Certificate of Accreditation of the Pollution Control Officer (PCO) duly issued by the
Department; or attach appointment/designation of PCO sign by the Managing Head together with
his/her bio-data/resume.

3. Copies of the quarterly self-monitoring reports for the immediately preceding year.

4. Official Receipts for the payment of the applicable Permit Fee and Wastewater Discharge Fee.

5. Description of the details and the cost of the upgrade or rehabilitation of the wastewater treatment
facilities (if any); and details of the changes in production technology (if any).

6. Photocopy of latest Wastewater Discharge Permit.

7. Other documents that may be required related to land application.

Failure to submit the necessary requirements shall be sufficient ground for the disapproval of the
application.