Department of Environment and Natural Resources

Environmental Management Bureau

Reference No:

(to be filled up by DENR only)

GENERAL INFORMATION SHEET

Name of the
Establishment/Facility
KARE PETRON SERVICE STATION

Establishment/Facility
Address J. Catolico Sr. Avenue, Lagao General Santos City
(NOT the company of head
office)

Name of Owner/Company VICTOR TAN REBOSURA

Address
(if address is not the same as
previous address)

Phone Number (083) 553-5273; 303-0599 Fax Number (083)553-5273

e-mail address
Type of Business/ Gasoline Refilling Station
Industry Classification
Responsible Officer/s: VICTOR TAN REBOSURA

Pollution Control Officer LOVELYN AQUINO-SANTOS

Legal Classification Single Proprietorship

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

VICTOR T. REBOSURA LOVELYN AQUINO-SANTOS

Name/Signature of Owner Name/Signature of PCO
Name of Plant: KARE PETRON SERVICE STATION
Address: J. Catolico Sr.Ave.,Lagao, General Santos City
Reference No:

Department of Environment and Natural Resources

Environmental Management Bureau

QUARTERLY SELF-MONITORING REPORT

3rd QUARTER 2011

MODULE 1: GENERAL INFORMATION

Name of the Plant KARE PETRON SERVICE STATION
Please provide the necessary revised, corrected or updated information not contained in your
General Information Sheet
Kare Petron Service Station is managed by Mr. Victor T. Rebosura. It provides 24
hours a day, seven days a week services to all private and public vehicles having 17
regular employees. It conveniently located along J. Catolico Sr. Avenue, Lagao, General
Santos City.
(use additional sheet/s if necessary)

DENR Permits/Licenses/Clearances
Environmental
Permits Date of Issue Expiry Date
Laws
A/C No. n/a n/a n/a
P.D. 984
PO No. 11-WDP-C-1263-069 March 12, 2011 March 12, 2012
ECC 1 12 05 04 20 069-120 April 28, 2005 No Expiration
PD 1586 ECC 2 n/a n/a n/a
ECC 3 n/a n/a n/a
DENR
Registry ID On process No Expiration
CCO Registry n/a n/a n/a
RA 6969 Importer
Clearance No n/a n/a n/a
Permit to
Transport n/a n/a n/a
A/C No. n/a n/a n/a
RA 8749
PO No. 11-POA-C-1263-159 April 28, 2011 March 14, 2012

Operation
Operating hours/day Operating days/week # of shift/day
Average 24 7 3
Maximum 24 7 3

Operation/Production/Capacity:
Average Daily Total Output this
Production Output Quarter
Total Water Total Electric
Consumption this 16.0 cu.m Consumption this 13,220 Kwh
Quarter (cubic meters) Quarter (KwH)

Module 1: General Information

Name of Plant: KARE PETRON SERVICE STATION
Address: J. Catolico Sr.Ave.,Lagao, General Santos City
Reference No:

Please use additional sheet/s if necessary

Module 1: General Information

Name of Plant: KARE PETRON SERVICE STATION
Address: J. Catolico Sr.Ave.,Lagao, General Santos City
Reference No:

MODULE 2: RA 6969

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

Common Name/IUPAC/CAS Index Name. ___

CAS No.: ___
Trade Name: ___

For importers only:

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

Not Applicable for this service station it is not an importer

of hazardous waste.

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

Not Applicable for this service station it is not an

importer/distributor of hazardous waste.

Total Quantity Distributed

For non-importer users:

Name of Distributor Quantity Date of Purchase

Not Applicable for this service station it is not an importer

of hazardous waste.

Total Quantity Purchased from Distributor

Module 2A: RA 6969 (CCO Report)

Name of Plant: KARE PETRON SERVICE STATION
Address: J. Catolico Sr.Ave.,Lagao, General Santos City
Reference No:

For producers
Average Daily Total Output this
Production Output None Quarter None
Quantity of Stock Quantity of Stock
Inventory (Start of Inventory (End of
Quarter)
None Quarter)
None
Name of Buyer Quantity Date of Purchase

Not Applicable for this service station it is not a producer

of hazardous waste.

Total Quantity Sold

Used in Production (please fill up only if chemical/substance is not main product)

Average Daily Total Output this
Production Output None Quarter None
Average Quantity Used None Total Quantity Used None
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 None Chemical Generated None
Generated per month this Quarter
Quantity of Stock None Quantity of Stock None
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)

Name of Plant: KARE PETRON SERVICE STATION
Address: J. Catolico Sr.Ave.,Lagao, General Santos City
Reference No:

B. Hazardous Wastes Generator

HW Generation:
HW Remaining HW from
HW Generated
HW No. HW Class HW Nature Cataloguin Previous Report
g 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: ___

Name: ___
Storage
Method: ___

ID: Name: ___

Transporter
Date: ___

ID: Name: ___

Treater
Method: Date: ___

ID: Name: ___

Disposal
Date: Date: ___

C. Hazardous Wastes Treater/Recycler

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

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

Not Applicable for this service station it is not a

recycler/treater of hazardous waste.

Module 2C: RA 6969 (Hazardous Wastes Treater/Recycler)

Name of Plant: KARE PETRON SERVICE STATION
Address: J. Catolico Sr.Ave.,Lagao, General Santos City
Reference No:

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

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

Not Applicable for this service station it is not a

recycler/treater of hazardous waste.

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

Type of
Process by
Storage
Type of which the Disposal Time Table
HW Number Quantity Container/
Wastes Wastes is Option for Disposal
# of
Generated
containers

Not Applicable for this service station it is not a

recycler/treater of hazardous waste.

Module 2C: RA 6969 (Hazardous Wastes Treater/Recycler)

Name of Plant: KARE PETRON SERVICE STATION
Address: J. Catolico Sr.Ave.,Lagao, General Santos City
Reference No:

MODULE 3: P.D. 984 (Water Pollution)

Water Pollution Data

Domestic wastewater Process wastewater
0.3 cu.m None
(cubic meters/day) (cubic meters/day)
Cooling water Others: ___________
None None
(cubic meters/day) (cubic meters/day)
Wash water, Wash water, floor
None None
equipment (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 No record of cost treatment for separate facilities
used by WTP
Utility Costs of WTP
incurred in this service station. The service station
(electricity & water) purely engaged in refilling of Gasoline, Diesoline, Gas
Administrative and & etc. no car washing services offered due to lack of
Overhead Costs customers availing the services because of the
Cost of operating in-
house laboratory proliferation of washing services in the adjacent area.
New/Additional
Investments in WTP
(Description)
Cost of New/Add
Investments

WTP Discharge Location

Outlet Number Location of the Outlet Name of Receiving Water Body
Oil-Water Separator Last Chamber Concrete Line Canal

Module 3: P.D. 984 (Water Pollution)

Name of Plant: KARE PETRON SERVICE STATION
Address: J. Catolico Sr.Ave.,Lagao, General Santos City
Reference No:

Detailed Report of Wastewater Characteristics for Conventional Pollutants

Outlet No.

Effluent Oil & ________

BOD TSS Temp rise (name)
DATE Flow Rate Color pH Grease
(mg/L) (mg/L) (ºC)
(m3/day) (mg/L)
(unit)

No in house sampling conducted for this quarter since

no car washing services offered, therefore no effluent
discharge had observed for this quarter.

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

Detailed Report of Wastewater Characteristics for Other Pollutants

Module 3: P.D. 984 (Water Pollution)

Name of Plant: KARE PETRON SERVICE STATION
Address: J. Catolico Sr.Ave.,Lagao, General Santos City
Reference No:

Outlet No.

Effluent ________ ________ ________ ________ ________ ________ ________

(name) (name) (name) (name) (name) (name) (name)
DATE Flow Rate
(m3/day)
(unit) (unit) (unit) (unit) (unit) (unit) (unit)

No in house sampling conducted for this quarter since

no car washing services offered, therefore no effluent
discharge had observed for this quarter.

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

Please use additional sheet/s if necessary.

Module 3: P.D. 984 (Water Pollution)

Name of Plant: KARE PETRON SERVICE STATION
Address: J. Catolico Sr.Ave.,Lagao, General Santos City
Reference No:

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

Summary of APSE/APCF
Process Equipment Location # of hrs of operations
Depending on the frequency
1. Standby Generator Within the Station
of brownout
2.
3.
4.
Fuel Burning Quantity
Location Fuel Used # of hrs of operations
Equipment Consumed
Depending on the
1. Standby Generator Within the Diesoline 10 ltrs/hr
frequency of brownout
Station
2.
3.
4.
5.
6.
Pollution Control Facility Location # of hrs of operations
1.
2.
3.
4.

Cost of Treatment
Month 1 Month 2 Month 3
Cost of Person Included in the Included in the Included in the
employed, (salary) payroll payroll payroll
Total Consumption of
4.8 cu.m 5.2 cu.m 6.0 cu.m
Water (cubic meters)
Total Cost of chemicals
used (e.g., activated None None None
carbon, KMnO4)
Total Consumption of
4,100 KwH 4,315 KwH 4,805 KwH
Electricity (KwH)
Administrative and
None None None
Overhead Costs
Cost of operating in-
None None None
house laboratory, if any
Improvement or
modification, if any. None None None
(Description)
Cost of improvement of
None None None
modification

Module 4: RA 8749 (Air Pollution)

Name of Plant: KARE PETRON SERVICE STATION
Address: J. Catolico Sr.Ave.,Lagao, General Santos City
Reference No:

Detailed Report of Air Emission Characteristics

Description/Location
of PCF
_______ _______
________ ________
Flow Rate CO NOx Particulates (name) _ _ (name)
DATE (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: RA 8749 (Air Pollution)

Name of Plant: KARE PETRON SERVICE STATION
Address: J. Catolico Sr.Ave.,Lagao, General Santos City
Reference No:

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

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

Not Applicable

(Please accomplish one table per sampling station.)

Other ECC Conditions

Status of Compliance
ECC Condition/s Actions Taken
Yes No
1. That it shall be the responsibility of the
project proponent to secure necessary permits
from other agencies concerned prior to project
implementation to include but not limited to the
following.
 DOH and/or City Health
Sanitation;
 City Engineer’s Office on
Drainage;
 City Building Offisials on
Structural Stability; √ Complied
 Office of the City Planning and
Development Coordinator on
Zoning Clearance; and
 Dept. of Labor on Occupational
Safety
That the implementation of their policy, rules
and regulations related to the project as well
as the monitoring regulation of the above
permits shall be the responsibility of the
respective government agencies concerned.
2. That the project shall conform with the
Comprehensive Land Use Plan (CLUP) of the
City otherwise this ECC shall be considered √ Complied
as null and void, ab initio;
3. That solid wastes generated during √ Complied

Module 5: P.D. 1586 (EIS System)

Name of Plant: KARE PETRON SERVICE STATION
Address: J. Catolico Sr.Ave.,Lagao, General Santos City
Reference No:

operation stage shall be properly handled,

collected and disposed in a sanitary manner
so as not to cause nuisance and in pursuant
to R.A. 9003 otherwise known as the
Ecological Solid Wastes Management Act;
4. That the project shall be properly and
adequately provided with appropriate fire
fighting equipment in order to prevent any fire √ Complied
incidence;
5. That a Wastewater Discharge Permit shall
be secured from this Office within thirty (30) √ Complied
days from the receipt of this ECC;
6. That the proponent shall establish a
sampling port at effluent discharges for √ Complied
sampling and monitoring purposes;
7. That appropriate tree species shall be
planted and maintained on open areas as part
of environmental rehabilitation and protection √ Complied
measures;
8. That the project shall exit from the coverage of
the EIA System once all conditions have been
complied with, and henceforth all regulatory Complied
activities shall be conducted by those regulatory √
agencies concerned, to include but not limited to
those that are indicated in Condition No. 2 of this
certificate;

9. That the proponent must undertake the following

information dissemination activities within (60)
days from receipt of this ECC:
a. To publish the ECC in a regional or local
news paper for two (2) consecutive
weeks; and
b. ECC billboards with dimension of 4 ft x 8
ft must be installed at entry/exit points
and perimeter of the project site facing Complied
the road. The billboard shall contain the
following message: “Notice to the Public,
This Project, Gasoline Service and Filling
Station has been issued and
Environmental Compliance Certificate
(ECC)
Proof of Compliance (original copies of the
newspaper, clippings and photographs of the
installed billboards) must be submitted to
EMB-RO12 within ninety days from the receipt
of this ECC;
10. That this ECC maybe amended or modified by √
the Office as the circumstances warrant or as the Complied
need arises with due notice to the Project
Proponent;
11. That any adverse impact caused by the project √
shall be the sole responsibility of the proponent; Complied
12. That on-the-spot monitoring and inspection
shall be initiated by the EMB-DENR 12 anytime to Complied
check compliance of the above stipulations; √
13. That the EMB reserves the right to cancel
withdraw this certificate and for any
misrepresentation of facts vital to the issuance of √ Complied
this certificate and for any violation of the
conditions stipulated hereof;
14. That any expansion of the proposed project

Module 5: P.D. 1586 (EIS System)

Name of Plant: KARE PETRON SERVICE STATION
Address: J. Catolico Sr.Ave.,Lagao, General Santos City
Reference No:

shall be subject to another EIA requirement; and √ Complied

15. That transfer of ownership of the project
carries the same conditions in this Certificate for Complied
which written notification shall be made within (15) √
days from such transfer.

Please use additional sheet/s if necessary.

Environmental Management Plan/Program

Status of Implementation
Enhancement/Mitigation Measures Actions Taken
Yes No
Segregation of Non
1.Disposal of Solid Waste at
Biodegradable and Complied
proper designated place Biodegradable
2. Regular maintenance of
√ Complied
generator.
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 230 kgs Wastes Generated this 690 kgs
Generated per month Quarter
Average Quantity of Total Quantity of Solid
Solid Wastes Collected Wastes Collected this 690 kgs
per month
230 kgs Quarter

Entity in charge of
collecting solid wastes LGU-GSC

Brief Description of Solid waste generated are placed in separate receptacle wherein
Solid Waste biodegradable, non-biodegradable and hazardous waste
Management Plan materials are properly segregated and collected by
(e.g., waste reduction,
government garbage disposal
segregation, recycling)

Module 5: P.D. 1586 (EIS System)

MODULE 6: OTHERS

Accidents & Emergency Records

Findings and Actions
Date Area/Location Remarks
Observation Taken

No cases of accidents &

Emergency cases for the
quarter.

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

No training seminar for this

quarter.

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

Done this _________________________, in ________________________.

VICTOR T. REBOSURA LOVELYN AQUINO-SANTOS

Name/Signature of Owner Name/Signature of PCO

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

VICTOR T. REBOSURA 03584013 Brgy.Lagao Jan.5, 2011

LOVELYN AQUINO-SANTOS 03584015 Brgy.Lagao Jan.5, 2011

Doc No. __________

Page No. _________
Book No. _________
Series No. ________
 KARE PETRON SERVICE STATION
J. Catolico Sr., Avenue, Lagao, General Santos City

October 11, 2011

DATU TUNGKO M. SAIKOL

Regional Director
Environmental Management Bureau
Department of Environment and Natural Resources
Region Office XII
Koronadal City

THRU: ENGR. RONIE L. SALMON

Chief, Pollution Control Division
EMB-DENR R-XII

Sir:

We are submitting herewith our duly notarized Third Quarter Self-Monitoring Report
(SMR) for Calendar Year 2011 for our Petron Service Station located at the above
address.

We hope that with this SMR, we would be in compliance to the EMB reporting
requirements.

Thank you.

Very truly yours,

LOVELYN AQUINO-SANTOS
Pollution Control Officer