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Republic of the Philippines Environmental Management Bureau Department of Environment and Natural Resources Region

 
 

DISCHARGE PERMIT

Permit No.

Date

Pursuant to Presidential Decree 984, as amended and its implementing rules and regulations, this permit is hereby granted to:

Name of Firm

 

Address

PERMIT CONDITIONS

1. The permit holder shall discharge at wastewater not exceeding: Wastewater Flow

,

for the period

, cubic meters per year and in

effluent

conformity with DENR Department Administrative Order No. 35, s. 1990 (Revised Effluent Regulations of 1990).

2. The permit holder shall submit self-monitoring reports on or before the following dates:

1 st Quarter 2 nd Quarter 3 rd Quarter 4 th Quarter

/ (day/month/year)

/

/ (day/month/year)

/

/ (day/month/year)

/

/ (day/month/year)

/

3. The permit holder shall allow entry, inspection of subject establishment or facility and compliance monitoring by this office.

 

4. This Permit shall be renewed at least one month before

;

5. This Permit is valid up to by this office.

,

unless sooner revoked or suspended for cause

Refusal or failure by permit holder to comply with the permit conditions and relevant laws, rules and reguilations implemented by this office may be sufficient cause for the revocation or suspension of this permit.

Evaluated by:

 

Approved by:

Chief, Environmental Quality Division

Director, EMB Region

 

WD Permit Fee O.R. No. :

Amount: PhP

Date :

 
 

This Permit should be posted in a conspicuous location near the structure and/or

 

Republic of the Philippines Department of Environment and Natural Resources ENVIRONMENTAL MANAGEMENT BUREAU DENR ( Regional Office & Address)

Telephone: (

)

Fax: (

)

APPLICATION FORM FOR DISCHARGE PERMIT

New

New

Renewal

Renewal Expiry Date TIN:

Expiry Date

TIN:

Application No.

New Renewal Expiry Date TIN: Application No. INSTRUCTION: Fill in all appropriate white spaces. Mark all
New Renewal Expiry Date TIN: Application No. INSTRUCTION: Fill in all appropriate white spaces. Mark all

INSTRUCTION: Fill in all appropriate white 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 City or Municipality

Barangay Province Accreditation Date Fax

 

Type of Industry Name of PCO Tel. No. & Cel No.

Legal Classification

Proprietorship Private Corporation

Multinational

Other: Specify

Ownership Terms (%)

Private

%

Foreign

%

Government

%

Employment and Operation Information

 

Total Employment (number of workers) in the factory:

 

Production

Non-Production:

Production Time:

Number of hours/day:

Number of days/month:

Number of months/year:

Sources of Water Supply and Wastewater Generation

 

Sources of Water Supply

 

Monthly Ave. Vol. (m 3 )

Daily Ave. Vol. (m 3 )

Generating Process

 

Estimated

Flo

(m

3 )

MWSS

(please

attach

water

   

Process Wastewater

   

bills)

 

Local

Water

District

(please

   

Washing/Cleaning

of

Process

 

water bills)

 

Equipment

Deep Well

     

Cooling

 

Surface Water (lake, river, creek, etc.)

   

Domestic

 

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 (m 2 ) Total Area for Dwelling Units

No. of Bedrooms No. of Restaurants/Dining Units

Number of Guests/year

2

Product Information

 

Product 1

Product 2

Product 3

Product Name

     

Actual Production Capacity

     

Actual Production in the previous year

     

Type of Process

Batch

Batch

Batch

Continuous

Continuous

Continuous

Note: **Please use generic product name, not in brand names, in metric tons of products except for the following substances: hog raising (heads) slaughtering/preserving

carbonated drinks and beers(m 3 )

Water Pollution Information

 

Location & Distribution of the Outlet

Number

of

the

Estimated

Ave.

Estimated Ave. rate of Discharge (m3/day)

Estimated

Ave.

BO

Outlet

Receiving body if not Discharging Directly in the Lake

BOD

Load (kg/day)

Number

 

Concentration

 

(mg/L)

1

 

2

3

 

Total

Name of Laboratory Performing Analysis Address of laboratory

Date of Sampling

Date of Analysis

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)

water bodies, etc. Use scale to fit into the frame below) Fixed Fee Official Receipt Number

Fixed Fee Official Receipt Number

I hereby certify that the above information are true and correct to the best of my knowledge. Done this

20

Name and Signature of the Pollution Control Officer

SUBSCRIBE AND SWORN to before a Notary Public. This

Receipt

Issued

Chief Executive Officer

day

of

Affiant exhibiting

day

of

of

to me his/her Community Tax

NOTARY PUBLIC

3