Department of Environment and Natural Resources

Environmental Management Bureau

Reference No:
(to be filled up by DENR only)

GENERAL INFORMATION SHEET

Name of the
SERVIAMUS MEDICAL CLINIC AND LABORATORY, INC.
Establishment/Facility

Establishment/Facility Street # & Street Name: Cor. Rosario-Verbena Sts. _________

Address Barangay: Brgy. 33 City/Municipality: _Bacolod City ___
(NOT the company of head
office) Province: Neg. Occ.
Name of
SERVIAMUS MEDICAL CLINIC AND LABORATORY, INC.
Owner/Company
Street # & Street Name: ___
Address
(if address is not the same as Barangay: City/Municipality: ___
previous address)
Province:

Phone Number (034) 474-6678 Fax Number

e-mail address [email protected]

Type of Business/ Philippine Standard Industry Classification Code No. 86900 ___
Industry Classification Philippine Standard Industry Descriptor: Clinical Laboratory

CEO/President. June Pearl T. Sanson

Tel #: 09175031719 Fax #: 4746678
e-mail address: [email protected] ___
Responsible Officer/s:
Plant Manager: N/A ___
Tel #: Fax #: ___
e-mail address: ___

Name. Michael Jim L. Sitchon

Pollution Control
Tel #: 09953243287 Fax #:
Officer
e-mail address: [email protected]

 single proprietorship  partnership

Legal Classification R private domestic corporation  government corporation
 Multi-national £ ___

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

June Pearl T. Sanson Michael Jim L.Sitchon

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 the Plant SERVIAMUS MEDICAL CLINIC AND LABORATORY, INC.
Please provide the necessary revised, corrected or updated information not contained in your General
Information Sheet
Serviamus Medical Clinic and Laboratory, Inc is a medical clinic and laboratory to serve the local residence and
out of town clients of Bacolod City seeking medical check-up or medical laboratory. The building has a total
gross floor area of 300 sqm and the number of patients in a day estimated about 15-25 persons. Number of
manpower is 10 persons and operates 6:00AM to 4:00PM daily (Monday-Friday).

(use additional sheet/s if necessary)

DENR Permits/Licenses/Clearances
Environmental
Permits Date of Issue Expiry Date
Laws
P.D. 984
A/C No. N/A
(RA 9275) PO No. (DP
No.)
R06-24-01227 2024-02-07 2025-01-06
ECC 1 N/A
PD 1586 ECC 2 N/A
ECC 3 N/A
DENR
Registry ID
OL-GR-R6-45-044714 2024-01-22
CCO Registry N/A
RA 6969 Importer
Clearance No
N/A
Permit to
Transport
N/A

Module 1: General Information page ____ of ____

Name of Plant:
Reference No:

A/C No. N/A

RA 8749
PO No. N/A

Operation
Operating hours/day Operating days/week # of shift/day
Average 10 hours 5 days/week 2
Maximum 10 hours 5 days/week 2

Operation/Production/Capacity:
Average Daily
N/A Total Output this Quarter N/A
Production Output
Total Water Consumption Total Electric
this Quarter (cubic 96 Consumption this Quarter 3840
meters) (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/IUPAC/CAS Index Name. N/A ___

CAS No.:
Trade Name: N/A ___

For importers only:

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

Total Quantity Requested Total Quantity Received

(annual) (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 from Distributor

For producers

Module 2B: RA 6969 (Hazardous Wastes Generator) page ____ of ____

Name of Plant:
Reference No:

Average Daily
N/A Total Output this Quarter N/A
Production Output
Quantity of Stock Quantity of Stock
Inventory (Start of N/A Inventory (End of N/A
Quarter) Quarter)
Name of Buyer Quantity Date of Purchase

Total Quantity Sold

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

Average Daily
N/A Total Output this Quarter N/A
Production Output
Average Quantity Used N/A Total Quantity Used this N/A
per month Quarter
Describe any changes in Production/Process/Operations:

Stock Inventory/Waste Chemical Generated:

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

Other Information:
Manner of handling R 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
B. Hazardous Wastes Generator

Module 2B: RA 6969 (Hazardous Wastes Generator) page ____ of ____

Name of Plant:
Reference No:

HW Generation:
Remaining HW from
HW HW Generated
HW No. HW Class HW Nature Previous Report
Cataloguing
Quantity Unit Quantity Unit
D407 Busted Solid Toxic 0.002 metric 0.002 metric
Flourescent tons tons
Lights
J201 Containers Solid Toxic 0.003 metric 0.003 metric
previously tons tons
containing
Toxic
Chemicals
M501 Pathological Solid Toxic 0.005 metric 0.1 metric
or tons tons
Infectious
Wastes
M506 Electronic Solid Toxic 0.003 metric 0.003 metric
Wastes tons tons
(Led
Lightings)

Waste Storage, Treatment and Disposal:(Please fill-up one table per HW)
HW No,: D407 ___
HW Details Qty of HW Treated: 0 Unit: metric tons
TSD Location: ___

Name: Busted Flourescent Lights

Storage
Method: Stored in bins in storage area

ID: Name: ___

Transporter
Date: ___

ID: Name: ___

Treater
Method: Date: ___

ID: Name: ___

Disposal
Date: Date: ___

HW No,: J201 ___

HW Details Qty of HW Treated: 0 Unit: metric tons
TSD Location: ___
Storage
Name: Containers previously containing Toxic Chemicals

Module 2B: RA 6969 (Hazardous Wastes Generator) page ____ of ____

Name of Plant:
Reference No:

Method: Stored in bins in storage area

ID: Name: ___

Transporter
Date: ___

ID: Name: ___

Treater
Method: Date: ___

ID: Name: ___

Disposal
Date: Date: ___

HW No,: M501 ___

HW Details Qty of HW Treated: 0 Unit: metric tons
TSD Location:

Name: Pathological or Infectious Wastes

Storage Method: Stored in sealed bins in storage area; waiting for an accredited TSD to pick
up waste

ID: Name: .
Transporter
Date:

ID: Name:
Treater
Method: Date:

ID: Name: ___

Disposal
Date: Date:

HW No,: M506 ___

HW Details Qty of HW Treated: 0 Unit: metric tons
TSD Location: ___

Name: Electronic Wastes (Led Lightings)

Storage
Method: Stored in bins in storage area

ID: Name: ___

Transporter
Date: ___

ID: Name: ___

Treater
Method: Date: ___

ID: Name: ___

Disposal
Date: Date: ___

Module 2B: RA 6969 (Hazardous Wastes Generator) page ____ of ____

Name of Plant:
Reference No:

On-Site Self Inspection of Storage Area:

Corrective Action Taken
Date Conducted Premises/Area Inspected Findings & Observations
(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:

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

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

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

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

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

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

Name of Plant:
Reference No:

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

Water Pollution Data

Domestic wastewater Process wastewater
3.692 m3 N/A
(cubic meters/day) (cubic meters/day)
Cooling water Others: ___________
N/A N/A
(cubic meters/day) (cubic meters/day)
Wash water, equipment Wash water, floor
N/A N/A
(m3/day) (cubic meters/day)

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

Month 1 Month 2 Month 3
Person employed, (# of
N/A N/A N/A
employees)
Person employed, (cost) N/A N/A N/A
Cost of Chemicals used
N/A N/A N/A
by WTP
Utility Costs of WTP
N/A N/A N/A
(electricity & water)
Administrative and
N/A N/A N/A
Overhead Costs
Cost of operating in-
N/A N/A N/A
house laboratory
New/Additional
Investments in WTP N/A N/A N/A
(Description)
Cost of New/Add N/A N/A N/A
Investments

WTP Discharge Location

Outlet
Location of the Outlet Name of Receiving Water Body
Number
1 Front of Building City Public Drainage
2
3
4
5

Module 3: P.D. 984 (Water Pollution) page ____ of ____

Name of Plant:
Reference No:

Detailed Report of Wastewater Characteristics for Conventional Pollutants

Outlet No. 1

Effluent Oil & ________

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

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) page ____ of ____

Name of Plant:
Reference No:

Outlet No.

Effluent ________ ________ ________ ________ ________ ________ ________

(name) (name) (name) (name) (name) (name) (name)
DATE Flow Rate
(m3/day)
(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: P.D. 984 (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. N/A N/A N/A
2.
3.
4.
Fuel Burning Quantity # of hrs of
Location Fuel Used
Equipment Consumed operations
1. N/A N/A N/A N/A N/A
2.
3.
4.
5.
6.
Pollution Control Facility Location # of hrs of operations
1. N/A N/A N/A

2.
3.
4.

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

Module 4: RA 8749 (Air Pollution) page ____ of ____

Name of Plant:
Reference No:

Detailed Report of Air Emission Characteristics

Description/Location
of PCF
________ ________ ________ ________
Flow Rate CO NOx Particulates (name) (name) (name) (name)
DATE
(Ncm/day) (mg/Ncm) (mg/Ncm) (mg/Ncm)
(mg/Ncm) (mg/Ncm) (mg/Ncm) (mg/Ncm)
N/A N/A N/A N/A N/A N/A N/A N/A N/A

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

Please use additional sheet/s if necessary.

Module 4: RA 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
Noise ________ ________ ________ ________
CO NOx Particulates (name) (name) (name) (name)
DATE Level
(mg/Ncm) (mg/Ncm) (mg/Ncm)
(dB) (mg/Ncm) (mg/Ncm) (mg/Ncm) (mg/Ncm)
N/A N/A N/A N/A N/A N/A N/A N/A N/A

(Please accomplish one table per monitoring station.)

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

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

(Please accomplish one table per sampling station.)

Module 5: P.D. 1586 (EIS System) page ____ of ____

Name of Plant:
Reference No:

Other ECC Conditions

Status of Compliance
ECC Condition/s Actions Taken
Yes No

1.
2.
3.
4.
5.
6.
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.
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 Quarter
Average Quantity of Total Quantity of Solid
Solid Wastes Collected Wastes Collected this
per month 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 System) page ____ of ____

Name of Plant:
Reference No:

MODULE 6: OTHERS

Accidents & Emergency Records

Findings and
Date Area/Location Actions Taken Remarks
Observation
None

Personnel/Staff Training
# of Personnel
Date Conducted Course/Training Description
Trained
Online 8-Hour Environmental 1
January 30,2024 Training Course for Managing
Heads

January 22-26,2024 40-Hour Basic Training Course 1

for Pollution Control Officers

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

Done this _________May 2024________________, in __Bacolod City_.

Michael Jim L. Sitchon, RN

Name/Signature of PCO
June Pearl T. Sanson, MD
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

_____________________ _____________ _______________ ______________
_____________________ _____________ _______________ ______________

Module 5: P.D. 1586 (EIS System) page ____ of ____