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Department of Environment and Natural Resources

Environmental Management Bureau


Reference No:
(to be filled up by DENR only)

GENERAL INFORMATION SHEET


Name of the
Establishment/Facility

Establishment/Facility Street # & Street Name: ___


Address Barangay: City/Municipality: ___
(NOT the company of head
office) Province:
Name of
Owner/Company
Street # & Street Name: ___
Address
(if address is not the same as Barangay: City/Municipality: ___
previous address)
Province:

Phone Number Fax Number

e-mail address

Philippine Standard Industry Classification Code No. ___


Type of Business/
Philippine Standard Industry Descriptor: ___
Industry Classification
___

CEO/President. ___
Tel #: Fax #: ___
e-mail address: ___
Responsible Officer/s:
Plant Manager: ___
Tel #: Fax #: ___
e-mail address: ___

Name. ___
Pollution Control
Tel #: Fax #: ___
Officer
e-mail address: ___

 single proprietorship  partnership


Legal Classification  private domestic corporation  government corporation
 Multi-national  ___

We hereby certify that the above information are true and correct.

Name/Signature of CEO/President Name/Signature of PCO


Name of Plant:
Reference No:

Department of Environment and Natural Resources


Environmental Management Bureau

QUARTERLY SELF-MONITORING REPORT

MODULE 1: GENERAL INFORMATION


Name of the Plant
Please provide the necessary revised, corrected or updated information not contained in your General
Information Sheet

(use additional sheet/s if necessary)

DENR Permits/Licenses/Clearances
Environmental
Permits Date of Issue Expiry Date
Laws
A/C No.
P.D. 984
PO No.

ECC 1

PD 1586 ECC 2

ECC 3
DENR
Registry ID
CCO Registry
RA 6969 Importer
Clearance No
Permit to
Transport
A/C No.
RA 8749
PO No.

Module 1: General Information page ____ of ____


Name of Plant:
Reference No:

Operation
Operating hours/day Operating days/week # of shift/day
Average
Maximum

Operation/Production/Capacity:
Average Daily
Total Output this Quarter
Production Output
Total Water Consumption Total Electric
this Quarter (cubic Consumption this Quarter
meters) (KwH)
Please use additional sheet/s if necessary

Module 1: General Information page ____ of ____


Name of Plant:
Reference No:

MODULE 2: RA 6969

A. CCO Report (please accomplish this section for each chemical/substance)

Common Name/IUPAC/CAS Index Name. ___


CAS No.: ___
Trade Name: ___

For importers only:


Import
Quantity Date of Quantity Country of Country of
Clearance Port of Entry
Requested Arrival Received* Origin Manufacture
No.

Total Quantity Requested Total Quantity Received


(annual) (annual)
* attach copy/s of Bill of Lading

For distributors (importers/non-importers)


Name of Client License No. Quantity Date of Distribution

Total Quantity Distributed

For non-importer users:


Name of Distributor Quantity Date of Purchase

Total Quantity Purchased from Distributor

Module 2B: RA 6969 (Hazardous Wastes Generator) page ____ of ____


Name of Plant:
Reference No:

For producers
Average Daily
Total Output this Quarter
Production Output
Quantity of Stock Quantity of Stock
Inventory (Start of Inventory (End of
Quarter) Quarter)
Name of Buyer Quantity Date of Purchase

Total Quantity Sold

Used in Production (please fill up only if chemical/substance is not main product)


Average Daily
Total Output this Quarter
Production Output
Average Quantity Used Total Quantity Used this
per month Quarter
Describe any changes in Production/Process/Operations:

Stock Inventory/Waste Chemical Generated:


Average Quantity of Total Quantity of Waste
Waste Chemical Chemical Generated this
Generated per month Quarter
Quantity of Stock Quantity of Stock
Inventory (Start of Inventory (End of
Quarter) Quarter)

Other Information:
Manner of handling  storage on-site  Treatment on-site
hazardous wastes  storage off-site  Treatment off-site

Changes in Safety  Yes (please attach copy of revised plan)


Management System  No

Chemical Substitute  Yes (please attach copy if not submitted/included in previous report/s or had been revised)
Plan  No

Module 2B: RA 6969 (Hazardous Wastes Generator) page ____ of ____


Name of Plant:
Reference No:

B. Hazardous Wastes Generator

HW Generation:
Remaining HW from
HW HW Generated
HW No. HW Class HW Nature Previous Report
Cataloguing
Quantity Unit Quantity Unit

Waste Storage, Treatment and Disposal :( Please fill-up one table per HW)
HW No,: ___
HW Details Qty of HW Treated: Unit: ___
TSD Location: ___

Name: ___
Storage
Method: ___

ID: Name: ___


Transporter
Date: ___

ID: Name: ___


Treater
Method: Date: ___

ID: Name: ___


Disposal
Date: Date: ___

HW No,: ___
HW Details Qty of HW Treated: Unit: ___
TSD Location: ___

Name: ___
Storage
Method: ___

ID: Name: ___


Transporter
Date: ___

ID: Name: ___


Treater
Method: Date: ___

ID: Name: ___


Disposal
Date: Date: ___

Module 2B: RA 6969 (Hazardous Wastes Generator) page ____ of ____


Name of Plant:
Reference No:

On-Site Self Inspection of Storage Area:


Corrective Action Taken
Date Conducted Premises/Area Inspected Findings & Observations
(if any)

Module 2B: RA 6969 (Hazardous Wastes Generator) page ____ of ____


Name of Plant:
Reference No:

C. Hazardous Wastes Treater/Recycler

HW Stored and/or Untreated as of End of Quarter:


Type of
Transport Storage Time Table
Wastes Date of
HW Number Permit/Date Valid until Quantity Container/ for
Generator Transport
of Issue # of Treatment
containers

HW Treated and/or Recycled as of End of Quarter:


Type &
Type of
Transport Quantity of
Type of Wastes Date of Treatment or
HW Number Permit/Date Quantity Recycled or
Wastes Generator Transport Recycling
of Issue Treated
Process
Product

Residual Wastes Generated from the Treatment and/or Recycling Operation:


Process by Type of
Type of which the Storage Disposal Time Table for
HW Number Quantity
Wastes Wastes is Container/ Option Disposal
Generated # of containers

Module 2C: RA 6969 (Hazardous Wastes Treater/Recycler) page ____ of ____


Name of Plant:
Reference No:

MODULE 3: P.D. 984 (Water Pollution)

Water Pollution Data


Domestic wastewater Process wastewater
(cubic meters/day) (cubic meters/day)
Cooling water Others: ___________
(cubic meters/day) (cubic meters/day)
Wash water, equipment Wash water, floor
(m3/day) (cubic meters/day)

Record of Cost of Treatment (Separate entries for separate facilities)


Month 1 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 in-
house laboratory

New/Additional
Investments in WTP
(Description)

Cost of New/Add
Investments

WTP Discharge Location


Outlet
Location of the Outlet Name of Receiving Water Body
Number
1
2
3
4
5

Module 3: P.D. 984 (Water Pollution) page ____ of ____


Name of Plant:
Reference No:

Detailed Report of Wastewater Characteristics for Conventional Pollutants


Outlet No.

Effluent Oil & ________


BOD TSS Temp rise (name)
DATE Flow Rate Color pH Grease
(mg/L) (mg/L) (ºC)
(m3/day) (mg/L)
(unit)

Please fill-up/accomplish separate form/s for other outlet/s.

Module 3: P.D. 984 (Water Pollution) page ____ of ____


Name of Plant:
Reference No:

Detailed Report of Wastewater Characteristics for Other Pollutants


Outlet No.

Effluent ________ ________ ________ ________ ________ ________ ________


(name) (name) (name) (name) (name) (name) (name)
DATE Flow Rate
(m3/day)
(unit) (unit) (unit) (unit) (unit) (unit) (unit)

Please fill-up/accomplish separate form/s for other outlet/s.


Please use additional sheet/s if necessary.

Module 3: P.D. 984 (Water Pollution) page ____ of ____


Name of Plant:
Reference No:

MODULE 4: R.A. 8749 (Air Pollution)

Summary of APSE/APCF
Process Equipment Location # of hrs of operations
1.
2.
3.
4.
Fuel Burning Quantity # of hrs of
Location Fuel Used
Equipment Consumed operations
1.
2.
3.
4.
5.
6.
Pollution Control Facility Location # of hrs of operations
1.
2.
3.
4.

Cost of Treatment
Month 1 Month 2 Month 3
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 in-
house laboratory, if any

Improvement or
modification, if any.
(Description)

Cost of improvement of
modification

Module 4: RA 8749 (Air Pollution) page ____ of ____


Name of Plant:
Reference No:

Module 4: RA 8749 (Air Pollution) page ____ of ____


Name of Plant:
Reference No:

Detailed Report of Air Emission Characteristics


Description/Location
of PCF
________ ________ ________ ________
Flow Rate CO NOx Particulates (name) (name) (name) (name)
DATE
(Ncm/day) (mg/Ncm) (mg/Ncm) (mg/Ncm)
(mg/Ncm) (mg/Ncm) (mg/Ncm) (mg/Ncm)

Please fill-up/accomplish separate form/s for other PCF/s.


Please use additional sheet/s if necessary.

Module 4: RA 8749 (Air Pollution) page ____ of ____


Name of Plant:
Reference No:

MODULE 5: P.D. 1586


Ambient Air Quality Monitoring (if required as part of ECC conditions)
Description/Locatio
n
of Monitoring
Station
________ ________ ________ ________
Noise CO NOx Particulate (name) (name) (name) (name)
DATE Level (mg/Ncm (mg/Ncm s
(dB) ) ) (mg/Ncm) (mg/Ncm (mg/Ncm (mg/Ncm (mg/Ncm
) ) ) )

(Please accomplish one table per monitoring station.)

Ambient Water Quality Monitoring (if required as part of ECC conditions)


Description/Location
of Sampling Station
________ ________ ________ ________ ________ ________ ________ ________
(name) (name) (name) (name) (name) (name) (name) (name)
DATE
(unit) (unit) (unit) (unit) (unit) (unit) (unit) (unit)

(Please accomplish one table per sampling station.)

Module 5: P.D. 1586 (EIS System) page ____ of ____


Name of Plant:
Reference No:

Other ECC Conditions


Status of Compliance
ECC Condition/s Actions Taken
Yes No

1.
2.
3.
4.
5.
6.
Please use additional sheet/s if necessary.

Environmental Management Plan/Program


Status of
Enhancement/Mitigation Measures Implementation Actions Taken
Yes No

1.
2.
3.
4.
5.
6.
Please use additional sheet/s if necessary.

Solid Waste Characterization/Information:


Average Quantity of Total Quantity of Solid
Solid Wastes Generated Wastes Generated this
per month Quarter
Average Quantity of Total Quantity of Solid
Solid Wastes Collected Wastes Collected this
per month Quarter
Entity in charge of
collecting solid wastes

Brief Description of
Solid Waste
Management Plan (e.g.,
waste reduction,
segregation, recycling)

Module 5: P.D. 1586 (EIS System) page ____ of ____


Name of Plant:
Reference No:

MODULE 6: OTHERS

Accidents & Emergency Records


Findings and
Date Area/Location Actions Taken Remarks
Observation

Personnel/Staff Training
# of Personnel
Date Conducted Course/Training Description
Trained

I hereby certify that the above information are true and correct.

Done this _________________________, in ________________________.

Name/Signature of PCO

Name/Signature of CEO

SUBSCRIBED AND SWORN before me, a Notary Public, this ________ day of
______________________, affiants exhibiting to me their Community Tax Receipts:

Name CTR No. Issued at Issued on


_____________________ _____________ _______________ ______________
_____________________ _____________ _______________ ______________

Module 5: P.D. 1586 (EIS System) page ____ of ____

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