Republic of the Philippines

Department Environment and Natural Resources

LAGUNA LAKE DEVELOPMENT AUTHORITY
ENVIRONMENTAL REGULATION DEPARTMENT
CLEARANCES AND PERMITS DIVISION
FISHPEN REGISTRATION AND FISHPEN FEE COLLECTION FOR YEAR
2011
INSTRUCTION:

1.
1.1
1.2
1.3
1.4
1.5

Fill up the blanks in BLOCK LETTER and

CHECK the appropriate individual boxes.

APPL. NO. ___________

DATE : ______________

GENERAL INFORMATION :
Name of Operator/Owner
: ____________________________________________________
Mailing Address : _______________________________________________________________
Business Address : ______________________________________________________________
Tel. No. : ________ Cellphone No.___________ FAX __________ Email _________________
Has there been any changes in the ownership or membership of your Fishpen
YES
NO
If yes, kindly indicate the following. Any changes in the membership should be supported by
documents (duly Notorized Deed of Assignment), copies of which should be submitted. (If
space provided is not enough, please use back of this page)

ASSIGNOR
_____________________
_____________________
_____________________
_____________________
_____________________

ASSIGNEE
_____________________
_____________________
_____________________
_____________________
_____________________

COMPLETE ADDRESS
_________________________________
_________________________________
_________________________________
_________________________________
_________________________________

1.6 Name of Authorized Representative filing the application (must be supported with notarized
Special Power of
Attorney)
Name
Mailing Address
Contact No. /Cellphone No
Position

:
:
:
:

__________________________________________
__________________________________________
__________________________________________
__________________________________________

2. INFORMATION ON EXISTING FISHPEN :

2.1 Location of Fishpen : _______________________________________________
(Brgy.)
(Town/City)
1996 FP Belt

1999 FP Belt

Area Awarded in 2003

2.2 Fishpen Location No. : ______________________________________________

2.3 Area as per Approved Location Plan : _________________
2.4 Location of main house and/or guardhouse :
Inside the registered area
No. of structure : ______________
Area covered
: ______________
Outside the registered area
No. of structure : ______________

Area covered

: ______________

2.5 No. of Personnel Employed: ___________________

2.6 Signboard:

WITH SIGNBOARD

WITHOUT SIGNBOARD

2.7 Point Source of Fingerlings ______________________________________________

2.8 Consignment Site of Harvested Stocks ____________________________________

SPECIES

3. PRODUCTION
BANGUS

TILAPIA

B.H CARP

OTHERS

3.1 No. of cropping per year

3.2 Latest date of stocking
3.3 Quantity of Stock
3.4 Recovery rate
3.5 Rearing/culture period
3.6 Volume of Harvest
3.7 Ave. No. of pieces per kilo
3.8 Ave. Weight per piece upon
harvest

*Kindly fill-out completely the above matrix since the information generated will be used to
establish a baseline data of production in Laguna de Bay.
I do hereby certify the information supplied are true and correct in my knowledge and belief.
I understand that the information contained herein shall be subject to verification and that my false
statements shall be ground for rejection of this application.

Checklist of Requirements to be attached as part of

Name
this application:

_______________________
Applicants Signature
Over Printed

Business /Mayors Permit

Barangay Clearance of Recognition (To be issued by the respective Barangay Captain)
Special Power of Attorney (duly notorized) in case of change of SPA
Latest Assets and Liabilities

Barangay Clearance (for new owners as a result of approved transfer of ownership)

REPUBLIC OF THE PHILIPPINES)

) S. S.

SUBSCRIBED AND SWORN to before me this _____ day of __________________________ at

____________________ affiant exhibiting to me his/her Community Tax Certificate No. ___________ issued at
___________________________ on ______________, 2011.
Doc. No. _______
Page No. _______
Book No. _______

Series of:___)__