Republic of the Philippines

DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCES

ENVIRONMENTAL MANAGEMENT BUREAU

Office of the Regional Director
Region IX, Western Mindanao
2/F Pastoriza Bldg., Datoc St., Gatas District, Pagadian City
(062) 215-4137

Application for Discharge Permit

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
Name of Establishment/Plant

Est. Code

Plant Address: No. & Street Name

Year Est.

Barangay

City or Municipality

Province

Type of Industry
Name of PCO

Accreditation Date

Tel. No. & Cel. No.

Fax No.

Legal Classification
Proprietorship

Private Corporation

Ownership Terms (%)

Multinational

Private

Others, specify

Foreign

Government

EMPLOYMENT AND OPERATION INFORMATION

Total Employment (number of workers) in the factory:

Production

Non-Production

Production Time: Number of Hours/day

Number of days/month

Number of months/year

SOURCES OF WATER SUPPLY AND WASTEWATER GENERATION

Sources of Water Supply

MWSS (Please
water bills)

Monthly Ave. Vol. (m3)

Daily Ave. Vol. (m3)

attach

Generating Process

Process Water

Local
Water
District
(Please attach water bills)

Washing/Cleaning of Process Water

Deep wells

Cooling

Surface waterbodies, river,

creek, etc.

Domestic

Others

Recycled/Reuse
Others (drinking water, gardening,
evaporation,
leaks,
product
component, etc.)

Total Water Consumption

Total
Volume
Wastewater

of

Discharge

Dwelling Units Information (hotels, condominium, restaurants, malls, etc)

Total Floor Area

No. of Bedrooms

Total Area for Dwelling Unit (m2)

No. of Restaurants/Dining Unit

No. of Guest/Year

Estimated Flow
(m3)

PRODUCTION INFORMATION
Product 1

Product 2

Product 3

Product Name

Actual Production

Actual Production in the Previous

Year

Type of Process

Batch
Continuous

Batch
Continuous

Batch
Continuous

Note: **Please use generic product name, not in brand names, in metric tons of product, carbonated drinks and beer (m3)
Except for the following substances: hog raising (heads), slaughtering/preserving

Water Pollution Information

Outlet Number

Location &
Distribution of
Outlet

Name of the
Receiving body if
not discharging in
the lake

Estimated Ave.
BOD/TSS conc.
(mg/L)

Estimated Ave.
Rate of Discharge
(m3/day)

Estimated
BOD/TSS
(kg/day)

Average Load

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:__________________________________ Date of Issue:___________________

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 Pollution Control Officer

______ _ ________________________
Chief Executive Officer

SUBSCRIBED AND SWORN to before a Notary Public. This ______________ day of ________________. Affiant exhibiting to me his/her
Community Tax Receipt No. _________________________________ issued at ____________________ on ________________________.

_________________________________
Notary Public
Doc. No.________
Page No.________
Book No.________
Series of ________

REQUIREMENTS FOR APPLICATION FOR A WASTEWATER DISCHARGE PERMIT

FOR NEW APPLICATION:
Name of Establishment:
Address:
A) Engineers Report
1. Vicinity Map
2. Nature of Project or Business
3. Production Capacity
Quantity or Volume and Generic Name/s of Product/s
4. Nature and character of the applicants wastewater and its physical and chemical composition

5. Total daily volume of discharge of raw wastewater

6. Treatment process and estimated treatment efficiency
7. Total daily volume of water consumption and discharge of final treated wastewater or effluent
8. The name of receiving body of water and its official water classification and in case of land discharge,
the nearest receiving body of water and its official water classification
9. Information on flow measurement equipment and procedure
10. Pollution prevention/Environmental System plan or program
11. DENR ID Number as hazardous waste generator (if applicable)
12. Statement of the cost incurred in the installation and maintenance of wastewater treatment facility, if any
13. Quality and quantity of abstracted water
14. Copy of ECC or CNC (if applicable)