Discharge Permit Application Form - r3.emb.gov.ph

1 Republic of the Philippines Department of Environment and Natural Resources ENVIRONMENTAL MANAGEMENT BUREAU Regional Office No. III Application FORM FOR Discharge Permit New Renewal Expiry Date: _____ TIN Application Number: _____ INSTRUCTION: Fill in all complete 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 the Establishment/Plant: _____ Est. Code: _____ Year EST: _____ Plant Address: No.

2 & Street Name: _____ Barangay: _____ City/Municipality: _____ Province: _____ Telephone No: _____ Fax No: _____ Type of Industry: _____ Name of PCO: _____ Accreditation Date: _____ Legal Classification Proprietorship: Private Corp: Multi-National: Ownership Private: _____% Foreign: _____% Government: _____% Employment and Operation Information Total Employment (number of workers) in the factory: _____ Production Non-Production Production Time: Number of hrs/day: _____ Number of days/mo: _____ Number of mos/yr: _____ Sources of Water and wastewater Generation Sources of Water Supply Monthly Ave.

3 Vol.(m3) Daily Ave. Vol. (m3) Generating Process Estimated Flow (m3/day) MWSS (pls. attach water bills) Washing/Cleaning of Process Equipment Local Water District (pls. attach water bills) Washing/Cleaning of Process Equipment Deep well Cooling Surface Water (lake, river, creek, etc.) Domestic Others Recycled/Reused Others (drinking water, gardening, evaporation, leaks, product component, etc.) Total Water Consumption Total Volume of Discharge wastewater Dwelling Units Information (hotels, condominiums, restaurants, malls, etc.)

4 Total Floor Area (m2): _____ No. of Bedrooms: _____ No. of Guests/yr: _____ Total Area/Dining Units: _____ No. of Restaurants/Dining Units: _____ Republic of the Philippines Department of Environment and Natural Resources ENVIRONMENTAL MANAGEMENT BUREAU Regional Office No. III Product Information Product 1 Product 2 Product 3 Product 4 Product Name Actual Production Capacity Actual Production in the previous years Type of Process Batch Continuous Batch Continuous Batch Continuous Batch Continuous Note: Please use generic product name, not brand names, in metric tons of products except for the substances.

5 Hog-raising (heads), carbonated drinks and beers (m3), slaughtering/preserving of meat (ton LWK), electroplating (m2) Water Pollution Information Outlet Number Location and Distribution of the Outlet Number of Receiving Body of Water if not discharging directly to the lake Estimated Ave. BOD/TSS Concentration (mg/L) Estimated Ave. Rate of Discharge (m3/day) Estimated Ave. BOD/TSS Load (kg/day) 1 2 3 Total Name of Laboratory Performing Analysis Address of Laboratory Date of Sampling Date of Analysis

6 Method of Sampling Vicinity Map (The map should show relative location of the establishment with respect to existing structures, landmarks, rivers and other waterbodies, etc. Use scale to fit in the frame below.) Fixed Fee Official Receipt Number I hereby certify that above information are true and correct to the best of my knowledge. Done this _____ day of _____ 20_____. _____ _____ Name and Signature of Pollution Control Officer Chief Executive Officer SUBSCRIBE AND SWORN to before a Notary Public. This _____ day of _____Affiant exhibiting to me his/her Community Tax Receipt issued at _____.

7