APPLICATION FORM FOR DISCHARGE PERMIT

EPD: FORM 99-01a (Rev.08/21/02) Republic of the Philippines New Renewal Application No.: Expiry Date

LAGUNA LAKE DEVELOPMENT AUTHORITY

Philippine Sugar Center Building, North Avenue, Diliman, Quezon City http://www.llda.gov.ph | info@llda.gov.ph INSTRUCTION: Fill in all appropriate white spaces. Mark all appropriate boxes with an "X" BOX A: General Information Name of Establishment/Plant Plant Address No. & Street Name City or Municipality Type of Industry Name of PCO Tel. No. & Cel.No. Legal Classification Ownership Terms Proprietorship Private Private Corp. % Multi-National Foreign

TIN:

Est. Code: Barangay Province

Year Est.

Accreditation Date Fax No.: Others: Specify % Government %

BOX B: Employment and Operation Information

Total employment (number of workers) in the factory: Production Time: No. of hours/day

Production No. of mos./year

Non-Production No. of days w/ discharge/mo.

No. of days/mo.

BOX C: Sources of Water Supply and Wastewater Generation Sources of Water Supply MWSS (please attach water bills) Local Water District (please attach water bills) Deep Well Surface water (lake, river, creek, etc.) Others
Monthly ave. vol. (m3) daily ave. vol. (m3)

Generating Process Process Wastewater Washing/Cleaning of Process Eqpt. Cooling Domestic Recycled/Reuse
Others (drinking water, gardening, evaporation, leaks, products components, etc.)

Estimated Flow (m3/day)

Total Water Consumption

Total Volume of Discharge Wastewater

BOX D: Dwelling Units Information (hotels, condominium, restaurants, malls, etc.) Total Floor Area (m2) Total Area for Dining Units BOX E: Product Information Product 1 Product Name** Annual Production Capacity Actual Production in the previous year Type of Process BOX F: Water Pollution Information Outlet Number Location & Description of the Outlet Name of the Receiving Body if NOT Discharging Directly in the Lake Estimated Average BOD Conc. (mg/L)
Estimated Average Rate of Discharge (m3/day) Estimated Average BOD Load (kg/day) Batch Continous Batch Continous Batch Continous Batch Continous

No. of Bedrooms No. of Restaurants/Dining Units

No. of Guests/year

Product 2

Product 3

Product 4

1 2 3 Total

BOX G: Flow Meter Information Flow meter is installed at: Influent Effluent Parshall Flume Both Total Plant Effluent Rectangular weir Triangle weir None Venturi meter

Type of flow meter and method used at (effluent side):

Direct Reading If others, please specify device and/or method:

Area Velocity Method

BOX H: Information on the Wastewater Treatment System Wastewater treatment system existing? Yes No Pesos Date primary system installed : Month Year If YES, what is the capacity m3/day

Value of capital investment in the wastewater treatment plant. Is there a primary treatment system? Yes No

If Yes, what is the composition of the physical treatment system? Screening Equalization Grit Removal Oil-Water separation (Flotation) Sedimentation (Primary Settling) If others, specify

Is there a chemical treatment?

Yes

No

Date chemical treatment installed: Month

Year

If Yes, what is the composition of the chemical treatment system? Adsorption Disinfection Flocculation/coagulation Yes No pH Adjustment Date installed : Month Anaerobic Digestion If others, specify If others, specify Year Oxidation/Stabilization (Pond)

Is there a secondary treatment system? Activated Sludge Trickling Filtration

Single Batch Reaction Rotating Biological Contact

BOX I : Vicinity Map (the map should show relative location of the establishment with respect to existing structures, landmarks, rivers, the lake and other water bodies, etc., use scale to fit into the frame below)

Note: **Please use generic name. Not brand names, in metric tons of products except for the following subsectors : hog raising (heads), carbonated drinks and beers (m3), slaugthering/preserving meat (ton LWK, electroplating (m2)). 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

Chief Executive Officer (Name, Signature and Position)

SUBSCRIBED AND SWORN to before me a Notary Public, This _____ day of _________________, affiant exhibiting to me his/her Community Tax Receipt No. _______________________________, issued at _____________________________, on ____________________.

NOTARY PUBLIC