Republic of the Philippines

Department of Environment and Natural Resources

Environmental Management Bureau-National Capital Region
National Ecology Center Compound, East Avenue, Diliman, Quezon City

APPLICATION FOR “PERMIT TO OPERATE” AIR POLLUTION SOURCE INSTALLATIONS (APSI)

Type: New Renewal or Extension Additional APSI or APCF

Change of Ownership Change of Name Modification/Amendment
1. General Information:
Name of Owner:
Address:
Name of Permittee:
Address: Zip Code:
TIN: Nature of Business:
Nature of Ownership: Single Proprietorship Partnership Corporation
Authorized Capital: Paid Up Capital: Date of Start of Operation
Name of CEO: _______ Tel. No._ Fax No.:
Total Employees: Office: Production

Office Operation: hrs/day days/wk Production Operation: hrs/day days/wk

2 2
Land Area Occupied: m Open Area: m Owned Leased Shared
Classification: Industrial Commercial Residential Agricultural

2. Raw Materials & Product Information Not Applicable

Raw Materials Quantity Products Quantity

3. List of APSI
APSI Control Facility Date Installed
(for new application)

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

__________________________________________ _________________________________________
Name and Signature of the Pollution Control Officer Name and Signature of the Chief Executive Officer

SUBSCRIBED AND SWORN to before me a Notary Public, this ____day of _________, affiant exhibiting to me
his/her (SSS/TIN/PRC/Passport ID No.) ____________________________, issued at __________________,
on ___________________.

FM-CPD-AW07 00 10-15-17
 Fees Amount Official Receipt No. Date
Filing P 600.00
PD 1856 P 10.00
Documentary Stamp P 15.00
Permit

Application No. Pre-evaluated by:

FM-CPD-AW07 00 10-15-17
INSTRUCTIONS

1. Fully accomplish this form and complete all the supporting documents indicated hereunder.
Submit all documents in duplicate copies to our Air & Water Permitting Section of the Clearance
and Permitting Division for screening and assessment fees.
2. Proceed to the Accounting Section for the issuance of “Order of Payment”. Thereafter, pay
to the Cashier Section the corresponding amount indicated in the “Order of Payment”.
3. Submit your application together with the official receipt to the Records Section and ask
for your receiving copy.
Your application shall be acted upon with thirty (30) working days and you shall be informed
of our action accordingly.

Types of Application Documents Required

 New Item Nos. , , , , ,  & 
 Additional/Modification Item Nos. , , , ,  & 
 Change of Name/Ownership Item Nos. , , & 
 Renewal Item Nos.  & 11

Supporting Documents
Engineer’s Report prepared by the Pollution Control Officer and approved
by the President/General Manager with at least containing the following:
 Company profile
 Amount of raw materials and finished products
 Material balance
 Process flow diagram indicating all sources of air emission or possible air emission
 Brief description of process.
 List of APSI and corresponding air pollution control facility (APCF) with complete
specifications
 Discussion of each APSI & APCF showing the process/mode of operation, design
criteria & efficiencies of the APCF, the quantities & types of pollutants in the final
emissions.
 Discussion of mitigating measures undertaken if APSI is not provided with APCF
 Pollution loading of the regulated air pollutants in tons/year.
 Drawing requirements in 50cm x 90 cm paper signed by the President/General Manager
and duly signed by PME/ChE or any appropriate engineer from the two.
 Vicinity Map;
 Plant & Machinery Layout showing the connection of the APSI to APCF;
 Plan & elevation drawings of each APSI & APCF.
 Sectional drawings of the APCF.
Copy of the Certificate of Accreditation of the Pollution Control Officer,
or appointment/designation as such by the Managing Head.

 Environmental Compliance Certificate (ECC) or Certificate of Non-Coverage (CNC) copy.

 Source Emission Test Requirement (if required).
 Copy of Recent “Permit to Operate” issued by the Office.
Copy of Discharge Permit, if applicable.
 Copy of Hazardous Waste Generator Registration ID, if applicable.

 Copy of SEC Registration Certificate & Articles of Incorporation.

 Copy of DTI Registration Certificate

11
Proof of compliance to permit conditions.

FM-CPD-AW07 00 10-15-17