Republic of the Philippines Environmental Management Bureau Department of Environment and Natural Resources Region ____ DISCHARGE PERMIT

___________ Permit No. ______________ Date

Pursuant to Presidential Decree 984, as amended and its implementing rules and regulations, this permit is hereby granted to: __________________________________ Name of Firm _______________________ Address

PERMIT CONDITIONS 1. The permit holder shall discharge at _________, for the period _______, effluent wastewater not exceeding: Wastewater Flow ___________ cubic meters per year and in conformity with DENR Department Administrative Order No. 35, s. 1990 (Revised Effluent Regulations of 1990). The permit holder shall submit self-monitoring reports on or before the following dates: 1st Quarter ___/___/___ (day/month/year) 2nd Quarter ___/___/___ (day/month/year) 3rd Quarter ___/___/___ (day/month/year) 4th Quarter ___/___/___ (day/month/year) The permit holder shall allow entry, inspection of subject establishment or facility and compliance monitoring by this office. This Permit shall be renewed at least one month before _________; This Permit is valid up to _____________, unless sooner revoked or suspended for cause by this office.

2.

3. 4. 5.

Refusal or failure by permit holder to comply with the permit conditions and relevant laws, rules and reguilations implemented by this office may be sufficient cause for the revocation or suspension of this permit. Evaluated by: ______________________________ Chief, Environmental Quality Division WD Permit Fee O.R. No. : __________ Approved by: ___________________________ Director, EMB Region ____ Amount: PhP________ Date : ________

This Permit should be posted in a conspicuous location near the structure and/or pequipment.

Republic of the Philippines Department of Environment and Natural Resources ENVIRONMENTAL MANAGEMENT BUREAU DENR ( Regional Office & Address) Telephone: (__________) Fax: (____________)

APPLICATION FORM FOR DISCHARGE PERMIT

New Renewal Application No. Expiry Date TIN:

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 Type of Industry Name of PCO Tel. No. & Cel No.

No. & Street Name City or Municipality

Barangay Province Accreditation Date Fax

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 Time: Number of hours/day: Production Non-Production: Number of days/month: Number of months/year:

Sources of Water Supply and Wastewater Generation Sources of Water Supply Monthly Ave. Vol. (m3) Daily Ave. Vol. (m3) Generating Process Estimated (m3) Flow

MWSS (please attach water bills) Local Water District (please water bills) Deep Well
Surface Water (lake, river, creek, etc.)

Process Wastewater Washing/Cleaning Equipment Cooling

Domestic

of

Process

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) Total Area for Dwelling Units No. of Bedrooms No. of Restaurants/Dining Units Number of Guests/year

Product Information

Product 1 Product Name Actual Production Capacity Actual Production in the previous year Type of Process Batch Continuous

Product 2

Product 3

Batch Continuous

Batch Continuous
carbonated drinks and beers(m3 )

Note: **Please use generic product name, not in brand names, in metric tons of products except for the following substances: hog raising (heads) slaughtering/preserving

Water Pollution Information Location & Distribution of the Outlet Number of the Receiving body if not Discharging Directly in the Lake Estimated Ave. BOD Concentration (mg/L) Estimated Ave. rate of Discharge (m3/day) Estimated Ave. Load (kg/day) BOD

Outlet Number 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 that 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 exhibiting to me his/her Community Tax Receipt No. _______Issued

NOTARY PUBLIC