Beruflich Dokumente
Kultur Dokumente
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
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.)
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
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.)
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:
Failure to submit the necessary requirements shall be sufficient ground for the disapproval of the
application.