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
(NOT the company of head Barangay: _______________________ City/Municipality: __________________
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

Type of Business/ Philippine Standard Industry Classification Code No. _______________________

Industry Classification Philippine Standard Industry Descriptor : ___________________________
CEO/President:_____________________________________________________
Tel # : ______________________ Fax #: _________________________

e-mail address: ___________________________

Responsible Officer/s:
Plant Manager:_____________________________________________________
Tel # : ______________________ Fax #: _________________________

e-mail address: ___________________________

Name :___________________________________________________________
Pollution Control Officer Tel # : ______________________ Fax #: _________________________

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

Q U A R T E R L Y S E L F-M O N I T O R I N G R E P O R T
1st Q 2nd Q 3rd Q 4th Q

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
Production Output Quarter
Total Water Total Electric
Consumption this Consumption this
Quarter (cubic meters) Quarter (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 Importer’s only:

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

Total Quantity Total Quantity

Requested (Annual) Received (annual)
* attach copy/s of Bill of Lading

For Distributor’s (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 2A: RA 6969 (CCO Report) page___
of____
Name of Plant:
Reference No:
__________________________________________________

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

Stock Inventory/Waste Chemical Generated:

Average Quantity of Total Quantity of Waste
Waste Chemical Chemical Generated
Generated per month this 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
 No
System
Chemical Substitute  Yes (please attach copy if not submitted/included in previous report/s or had been revised)
Plan  No

_____________________________________________________________________________
Module 2A: RA 6969 (CCO Report) page___
of____
Name of Plant:
Reference No:
__________________________________________________

B. Hazardous Waste 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
Method_________________________ 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
Method_________________________ Date: _____________________
_____________________________________________________________________________
Module 2B: RA 6969 (Hazardous Waste Generator) page___
of____

Name of Plant:
Reference No:
__________________________________________________

On-Site Self Inspection of Storage Area:

Premise/Area Findings & Corrective Action
Date Conducted
Inspected Observations Taken (if any)
_____________________________________________________________________________
Module 2B: RA 6969 (Hazardous Waste Generator) page___
of____
Name of Plant:
Reference No:
__________________________________________________

C. Hazardous Waste Treater/Recycler

HW Stored and/or Untreated as End of Quarter:

Type of
Transport Storage Timetable
HW Waste Date of Valid
Permit/Date Quantity Container/ for
Number Generator Transport Until
of Issue # of Treatment
containers

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

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

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

Type of
Process by
Storage
Type of HW which the Disposal Time Table
Quantity Container/
Wastes Number Wastes is Option for Disposal
# of
Generated
containers
_____________________________________________________________________________
Module 2C: RA 6969 (Hazardous Waste 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, Wash water, floor
equipment (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 & Temp

BOD TSS (name)
Date Flow Rate Color pH Grease rise
(mg/L) (mg/L)
(m3/day) (mg/L) (0C)
(name)
Please fill-up/accomplish separate form/s for other outlets

_____________________________________________________________________________
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) (name)
(name) (name) (name) (name) (name) (name)
Please fill-up/accomplish separate form/s for other outlets.
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 hours of operation
1.
2.
3.
4.
Fuel Burning Quantity # of hours of
Location Fuel Used
Equipment Consumed operation
1.
2.
3.
4.
5.
6.
Pollution Control Facility Location # of hours of operation
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 Costs 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: R.A. (Air Pollution) page___
of____
Name of Plant:
Reference No:
__________________________________________________

Detailed Report of Wastewater Characteristics for Other Pollutants

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 outlets.
Please use additional sheet/s if necessary

_____________________________________________________________________________
Module 4: R.A. (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/Location
of Monitoring Station

Noise CO NOx Particulates (name) (name) (name) (name)

Date
Level (dB) (mg/NCM) (mg/NCM) (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
Monitoring Station

(name) (name) (name) (name) (name) (name) (name) (name)

Date
(name) (name) (name) (name) (name) (name) (name) (name)
(Please accomplish one table per monitoring station)
Module 5: P.D. 1586 (EIS System) page___
of____

Name of Plant:
Reference No:
__________________________________________________

Other ECC Conditions

Status of
ECC Conditions Compliance Actions Taken
Yes No
1.
2.
3.
4.
5.
6.
7.
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.
7.
Please use additional sheet/s if necessary

Solid Waste Characterization/Information:

Average Quantity of Solid Total Quantity of Solid
Wastes Generated per Wastes Generated
Month this Quarter
Average Quantity of Solid Total Quantity of Solid
Wastes collected per Wastes Collected this
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 of/Signature of PCO

______________________________________
 Name of/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

________________________ _____________ ____________ ___________

________________________ _____________ ____________ ___________