Department of Environment and Natural Resources

Environmental Management Bureau

Reference No.:

( to be filled up be DENR only)

GENERAL INFORMATION SHEET

Name of the
Establishment/Facility
Establishment/Facility Street# & Street Name: __________________________________________________
Address Barangay: ___________________________________________ City/Municipality: ___________________________
(NOT The company of Province:_____________________________________________
head office)
Name of
Owner/Company
Address Street# & Street Name: __________________________________________________
(if address is not the Barangay: __________________________________________ City/Municipality:____________________________
same as previous Province:____________________________________________
address)
Phone Number Fax Number

e-mail address
Type of Business/ Philippine Standard Industry Classification Code No. ____________________________________________________
Industry Philippine Standard Industry Descriptor: _______________________________________________________________
Classification ____________________________________________________________________________________________________
CEO/President: _____________________________________________________________________________________
Tel #:_____________________________________________ Fax
Responsible #:________________________________________
Officer/s: e-mail address: ______________________________________________________________________________________
Plant Manager: ______________________________________________________________________________________
Tel #:_____________________________________________ Fax
#:________________________________________
e-mail address: ______________________________________________________________________________________
Pollution Control Name::______________________________________________________________________________________________
Officer Tel #:_____________________________________________ Fax
#:________________________________________
e-mail address: ______________________________________________________________________________________
Legal Classification  Single proprietorship  Partnership
 Private domestic corporation  Government corporation
 Multi-national  ____________________________________
We hereby certify that the above information are true and correct.

________________________________________ ________________________________________
Name/Signature of CEO/President Name/Signature of PCO
Name of Plant : Reference No.:
____________________________________________________________________________

Department of Environment and Natural Resources

Environmental Management Bureau

QUARTERLY SELF-MONITORING REPORT

MODULE 1: GENERAL INFORMATION

Name of Plant
Please provide the necessary revised, corrected or updated information not contained in your
General Information Sheet

( use additional sheet/s if necessary)

DENR Permits/Licenses/Clearances
Environmental Laws Permits Date of Issue Expiry Date
R.A. 9275 A/C No. n/a
PO. No. 14-DP-B-137201-055 April 20, 2014 February 8,
2015
ECC 1
PD 1586 ECC 2
ECC 3
DENR GR-13-74-1637 September 21,
Registry ID 2012
CCO Registry n/a
RA 6969 Importer n/a
Clearance No.
Permit to n/a
Transport
RA 8749 A/C No. n/a
PO No. 12-POA-B-137401-106® February 14, 2012 February 15,
2017
Module 1: General Information page _____ of _____
Name of Plant : Reference No.:
____________________________________________________________________________

Operation
Operating hours/day Operating days/week # of shift/day
Average
Maximum

Operation/Production/ Capacity:
Average Daily Production Total Output this Quarter
Output
Total Water Consumption Total Electric Consumption
this Quarter ( cubic meters) this Quiarter (KwH)
Please use additional sheet/s if necessary
Module 1: General Information page _____ of
_____
Name of Plant : Reference No.:
____________________________________________________________________________

MODULE 2: RA 6969

A. CCO Report (please accomplish this section for each chemical/substance)

Common Name/ UPAC/CAS Index Name: _______________________________________________________________

_______________________________________________________________ CAS No.:______________________________
Trade Name: __________________________________________________________________________________________

For importers only:

Quantity Import Date of Quantity Port of Country of Country of
Requested Clearance Arrival Received Entry Origin Manufacture
No.

Total Quantity Total Quantity

Requested ( annual) Received ( annual)
*attach copy/s of Bill of Lading

For Distributors (Importers/Non-importers)

Name of Client License No. Quantity Date of Distribution

Total Quantity Distributed

For Non-importer users:

Name of Distributor Quantity Date of Purchase

Total Quantity Purchased form Distributor

Module 2A: RA 6969 ( CCO Report )
page _____ of _____
Name of Plant : Reference No.:
____________________________________________________________________________

For producers
Average Daily Total Output this
Production Output Quarter
Quantity of Stock Quantity of Stock
Inventory( Start of Inventory( End of
Quarter) Quarter)
Name of Buyer Quantity Date of Purchase

Total Quantity Sold

Used in Production (please fill up only if chemicals/substances is not main product)

Average Daily Total Output this
Production Output Quarter
Average Quantity Used Total Quantity Used
per month this Quarter

Describe any changes in Production/Process/Operations:

Stock Inventory/ Waste Chemical Generated:

Average Quantity of Total Quantity of Waste
Waste Chemical Chemical Generated
Generated per month this quarter
Quantity of Stock Quantity of Stock
Inventory ( Start of Inventory ( End of
Quarter) Quarter)

Other Information:
Manner of handling  Storage on-site  Treatment on-site
hazardous wastes  Storage off-site  Treatment off-site
Changes in Safety  Yes( Please attach copy of revised plan)
Management System  No
Chemical Substitute  Yes( Please attach copy if not submitted/included in previous report/s or had been revised)
Plan  No
Module 2A: RA 6969 ( CCO Report ) page _____ of _____
Name of Plant : Reference No.:
____________________________________________________________________________

B. Hazardous Wastes Generator

HW Generation:
HW Remaining HW from HW Generated
HW No. HW Class HW Nature Cataloguing Previous Report
Quantity Unit Quantity Unit

Waste Storage, Treatment and Disposal: (Please fill-up one table per HW)
HW No. :_________________________________________________________________________________________
HW Details QTY. of HW Treated: ________________________________________________________ Unit: _________________
TSD Location :_____________________________________________________________________________________
Storage Name:____________________________________________________________________________________________
Method: __________________________________________________________________________________________
ID:_______________________________ Name: ___________________________________________________________
Transporter Date:_______________________________________________________________________________________________
Treater ID:_______________________________ Name: ___________________________________________________________
Method: ____________________________________________________________Date:___________________________
Disposal ID:_______________________________ Name: ___________________________________________________________
Date: ______________________________________________Date:____________________________________________

HW No.: ___________________________________________________________________________________________
HW Details Qty of HW Treated: _____________________________________________________ Unit: _______________________
TSD Location :_______________________________________________________________________________________
Storage Name:____________________________________________________________________________________________
Method: __________________________________________________________________________________________
ID:_______________________________ Name: ___________________________________________________________
Transporter Date:_______________________________________________________________________________________________
Treater ID:_______________________________ Name: ___________________________________________________________
Method: ____________________________________________________________Date:___________________________
Disposal ID:_______________________________ Name: ___________________________________________________________
Date: ______________________________________________Date:____________________________________________
Module 2B: RA 6969 (Hazardous Wastes Generator)
page _____ of _____
Name of Plant : Reference No.:
____________________________________________________________________________

On-Site Self Inspection of Storage Area:

Date Conducted Premises/Area Findings& Corrective Actions
Inspected Observations Taken ( if any)
Module 2B: RA 6969 (Hazardous Wastes Generator) page _____ of _____

Name of Plant : Reference No.:

____________________________________________________________________________

C. Hazardous Wastes Treater/ Recycler

HW Stored and/or Untreated as of End of Quarter:

Transport Type of
HW Number Wastes Date of Permit/Date Valid Until Quantity Storage Time Table for
Generator Transport of Issue Container/# Treatment
of Containers

HW Treated and/or Recycled as of End of Quarter:

Transport Type of Type &
Type of HW Number Wastes Date of Permit/Date Quantity Treatment or Quantity of
Wastes Generator Transport of Issue Recycling Recycled or
Process Treated
Product

Residual Wastes Generated from the Treatment and/or Recycling Operation:

Process by Type of Storage
which the Quantity Container/# of Disposal Option Time Table
Type of Wastes HW Number
Wastes is Containers For Disposal
Generated
Module 2C: RA 6969 (Hazardous Wastes Treater/ Recycler) page
_____ of _____
Name of Plant : Reference No.:
____________________________________________________________________________

MODULE 3: R.A. 9275 (Water Pollution)

Water Pollution Data

Domestic wastewater Process wastewater

(cubic meters/day) (cubic meters/day)
Cooling water (cubic Others: __________
meters/day) Wash (cubic meters/day)
water, equipment Wash water, floor
(m3/day) (cubic meters/day)

Record of Cost of Treatment (Separate entries for separate facilities)

Month 1 Month 2 Month 3
Person employed, (# of
employees)
Person employed, (cost)
Cost of Chemicals used by
WTP
Utility Costs of WTP
(electricity & water)
Administrative and
Overhead Costs
Costs of operation in house
laboratory

New/Additional
Investment in WTP
(Description)

Costs of New/Add
Investment

WTP Discharge Location

Outlet
Number Location of the Outlet Name of Receiving Water Body

1
2
3
4
5
 (Water Pollution)
Module 3: R.A. 9275
page _____ of _____
Name of Plant : Reference No.:
____________________________________________________________________________

Detailed Report of Wastewater Characteristics for Conventional Pollutants

Outlet No.

DATE Effluent BOD TSS Oil & Temp (name)

Flow Rate (mg/L) (mg/L) Color pH Grease rise (o C)
(m3/da (mg/L)
(unit)

Please fill-up/accomplish separate form/s for other outlet/s.

Module 3: R.A. 9275 (Water Pollution) page _____ of
_____
Name of Plant : Reference No.:
____________________________________________________________________________

Detailed Report of wastewater Characteristics for Other Pollutants

Outlet No.
Effluent
DATE Flow Rate (name) (name) (name) (name) (name) (name) (name)
(m3/da
(unit) (unit) (unit) (unit) (unit) (unit) (unit)

Please fill-up/accomplish separate form/s for other outlet/s.

Please use additional sheet/s if necessary.
Module 3: R.A. 9275 (Water Pollution) page _____ of
_____
Name of Plant : Reference No.:
____________________________________________________________________________

MODULE 4: R.A. 8749 (Air Pollution)

Summary of APSE/APCF

Process Equipment Location # of hrs of operations

1.
2.
3.
4.
Fuel Burning Location Fuel Used Quantity # of hrs of
Equipment Consumed operation
1.
2.
3.
4.
5.
6.
Pollution Control Facility Location # of hrs of operation
1.
2.
3.
4.

Cost of Treatment
Month 1 Month 2 Month 3
Cost of Person
employed, (salary)
Total Consumption of
Water (cubic meters)
Total Cost of
chemicals used (e.g.,
activated carbon,
KMnO4)
Total Consumption of
Electricity (KwH)
Administrative and
Overhead Costs
Cost of operation in-
house laboratory, if
any
Improvement or
modification, if any.
(Description)

Cost of improvement
of modification
Module 3: R.A. 8749 (Air Pollution) page _____ of
_____
Name of Plant : Reference No.:
____________________________________________________________________________

Detailed Report of Air Emission Characteristics

Description/Location
of PCF

DATE Flow Rate CO NOx Paticulates (name) (name) (name) (name)

(Ncm/day (mg/Ncm) (mg/Ncm) (mg/Ncm) (mg/Ncm) (mg/Ncm) (mg/Ncm) (mg/Ncm)

Please fill-up/accomplish separate form/s for other PCF/s.

Please use additional sheet/s if necessary.
 Module 4: R.A. 8749 (Air Pollution) page _____ of
_____
Name of Plant : Reference No.:
____________________________________________________________________________

MODULE 5: P.D. 1586

Ambient Air Quality Monitoring (if required as part of ECC conditions)

Description/Location
of Monitoring Station

DATE Noise Level CO NOx Particulates (name) (name) (name) (name)

(dB) (mg/Ncm) (mg/Ncm) (mg/Ncm) (mg/Ncm) (mg/Ncm) (mg/Ncm) (mg/Ncm)

(Please accomplish one table per monitoring station.)

Ambient Water Quality Monitoring (if required as part of ECC conditions)

Description
/Location
of Sampling (name) (name) (name) (name) (name) (name) (name) (name)
Station
(unit) (unit) (unit) (unit) (unit) (unit) (unit) (unit)
DATE

(Please accomplish one table per sampling station.)

Module 5: P.D. 1586 (EIS Systen) page _____ of
_____
Name of Plant : Reference No.:
____________________________________________________________________________

Other ECC Conditions

Status of Compliance
ECC Condition/s Yes No Actions Taken

1.
2.
3.
4.
5.
6.
7.
Please use additional sheet/s if necessary.

Environmental Management Plan/Program

Status of
Enhancement/Mitigation Measures Implementation Actions Taken
Yes No
1.
2.
3.
4.
5.
6.
7.
Please use additional sheet/s if necessary.

Solid Waste Characterization/Information:

Average Quantity of Total Quantity of Solid

Solid Wastes Generated Wastes Generated this
per month Average Quarter Total Quantity
Quantity of Solid Wastes of Solid Wastes Colleted
Collected per month this Quarter

Entity in charge of
collecting solid wastes

Brief Description of
Solid Waste
Management Plan (e.g.,
waste reduction,
segregation, recycling)

Module 5: P.D. 1586 (EIS Systen) page _____ of _____

MODULE 6: OTHERS

Accidents & Emergency Records

Date Area/Location Findings and Actions Taken Remarks

Observation

Personnel/Staff Training
# of Personnel Trained
Date Conducted Course/Training Description

I hereby certify that the above information are true and correct.

Done this ______________________________________, in _____________________.

_________________________________
Name/Signature of PCO
___________________________
Name/Signature of CEO

SUBSCRIBED AND SWORN before me, a Notary Public, this _______ day of ______________,
affiants exhibiting to me their Community Tax Receipts:

Name CTR No. Issued at Issued on

_____________________ ______________ _____________ ______________
_____________________ ______________ _____________ ______________