Republic of the Philippines

Department of Environment and Natural Resources

ENVIRONMENTAL MANAGEMENT BUREAU-1
Lingsat, San Fernando City, La Union
Telephone: (072) 242-3057 / 700-2448Fax: (072) 700-2449

APPLICATION FORM FOR DISCHARGE PERMIT

New □
Renewal □ Expiry Date: TIN :

Application No.

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 Barangay

| City of Municipality Province
Type of Industry Accreditation Date:
Name of PCO Fax
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 Daily Ave. Generating Process Estimated Flow
Ave. Vol. (m³) (m³)
Vol. (m³)
MWSS (please attach water bills) Process Wastewater
Local Water District (please water bills) Washing/ Cleaning of Process 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 (m²) No. of Bedrooms Number of Guests/year

Total Area for Dwelling Units No. of Restaurants/Dining Units
 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 carbonated drinks and beers(m³) except for the
Following substances: hog raising (heads) slaughtering/preserving

Water Pollution Information

Location & Distribution of the Number of the Receiving Body if Estimated Ave. Estimated Ave. rate Estimated Ave. BOD
Outlet Outlet not Discharging in the Lake BOD of Discharge Load (kg/day)
Number Concentration (m³/day)
(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.)

Fixed Fee Official Receipt Number

I hereby certify the above information are true and correct to the best of my knowledge. Done this ____________
Day of ________ of 20______.

_____________________________________ ______________________________________
Name and Signature of the Pollution Control Officer Chief Executive Officer

SUBSCRIBE AND SWORN to before a Notary Public. This ________ day of ________. Affiant to me his/her Community Tax Receipt
No._________ Issued.

NOTARY PUBLIC
 REQUIREMENTS FOR
WASTEWATER DISCHARGE PERMIT APPLICATION

Engineering Report prepared by a registered chemical or sanitary engineer containing the following:

a) vicinity map identifying the street address, location of plant premise;

b) the nature of project or business;
c) production capacity, quantity or volume and the generic name(s) of product(s);
d) the nature and character of the applicant’s wastewater and its physical and chemical
composition; BOD, TSS, Oil and Grease backed by computations or laboratory analysis
e) total daily volume of discharge of raw wastewater;
f) treatment process and estimated treatment efficiency;
g) total daily volume of water consumption and discharge of final treated wastewater or effluent;
h) the name of the 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;
i) information on flow measurement and equipment and procedure;
j) Pollution Prevention and Environmental Management System plan or program;
k) DENR ID Number as hazardous waste generator (if applicable);
l) statement of the cost incurred in the installation and maintenance of wastewater treatment facility,
if any;
m) quality and quantity of abstracted water; and
n) copy of the Environmental compliance Certificate (ECC) from the Department or Certificate of
Non-Coverage (CNC) as applicable.
2. DTI Registration
3. TIN No.
4. Picture of Wastewater Treatment Facility

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