Department of Environment and Natural Resources

Environmental Management Bureau

Reference No:

(to be fill ed up by DENR only)

GENERAL INFORMATION SHEET

Name of the
Establishment/Facility Ela & Twins Gasoline Station
Establishment/Facility Street # & Street Name: Zone 3
Address
(NOTthe company of head Barangay: San Isidro City/Municipality: Lupao Province: Nueva Ecija
office)
Razil M. Carreon
Name of
Owner/Company
Street # & Street Name: Zone 3

Address Barangay: San Isidro City/Municipality: Lupao Province: Nueva Ecija

(if address is not the same as
previous address)

Phone Number 0997-733-3836 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 e-mail address:

Officer/s: Plant Manager:
Tel #: Fax #:
e-mail address:

Name.
Pollution Control
Tel #: Fax #:
Officer
e-mail address:

🖙 single proprietorship 🖙 partnership

Legal Classification 🖙 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

3rd QUARTER SELF - MONITORING REPORT

MODULE 1: GENERAL INFORMATION

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

Ela & Twins Gasoline Station

(Razil M. Carreon) is a filling Gasoline
Station located at Brgy. San Isidro,
Lupao, Nueva Ecija

(use additional sheet/s if necessary)

DENR Permits/Licenses/Clearances
Environmental
Permits Date of Issue Expiry Date
Laws
A/C No.
P.D. 984
PO No.

ECC 1 CNC-R03-1311-0029 2013-11-21

PD 1586 ECC 2 R03-1311-0129 2016-11-11 2021-12-30

ECC 3
DENR G3-R3-49-00067 2017-06-05
Registry ID
CCO Registry
RA 6969 Importer
Clearance No
Permit to ILGU-BPLS-2021-0355 2021-01-01 2021-12-31
Transport
A/C No. FLA-16L-03NE-041 2016-11-11 2021-12-30
RA 8749
PO No.

Module 1: General Information page of

Name of Plant:
Reference No:

Operation
Operating hours/day Operating days/week # of shift/day
Average 12 7 1

Maximum 12 7 1

Operation/Production/Capacity:
Average Daily N/A Total Output this N/A
Production Output Quarter
Total Water 250 Total Electric 3,600
Consumption this Quarter Consumption this Quarter
(cubic 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.

C AS 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.

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 from 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 chemical/substance 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 Waste Total Quantity of Waste
Chemical Generated per Chemical Generated this
month 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 Plan 🖙 Yes (please attach copy if not submitted/included in previous report/s or had been revised)
🖙 No

Module 2A: RA 6969 (CCO Report) page of

 Name of Plant:
Reference No:

B. Hazardous Wastes

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

Nam e:
Storage
Method:

ID: Name:
Transporter
Date:

ID: Name:
Treater
Method: Date:

ID: Name:
Disposal
Date: Date:

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:

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

 Name of Plant:
Reference No:

On-Site Self Inspection of Storage Area:

Premises/Area Findings & Corrective Action
Date Conducted
Inspected Observations Taken (if any)
2021-04-07 ELA & TWINS GAS N/A N/A
STATION

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

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

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

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

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 1/4 Process wastewater (cubic 1/4
(cubic meters/day) meters/day)
Cooling water 1/4 Others: ___________ 1/4
(cubic meters/day) (cubic meters/day)
Wash water, equipment 1/4 Wash water, floor 1/4
(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
Cost of operating in-
house laboratory

New/Additional
Investments in WTP
(Description)

Cost of New/Add
Investments

WTP Discharge Location

Outlet
Location of the Outlet Name of Receiving Water Body
Number
1
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.
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.

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

Name of Plant:
Reference No:

Detailed Report of Wastewater Characteristics for Other Pollutants

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. Pumps Brgy. San Isidro, Lupao, Nueva Ecija 1080

2.
3.
4.
Fuel Burning Quantity # of hrs of
Location Fuel Used
Equipment Consumed operations
1. 1 unit underground Brgy. San Isidro, Lupao, Premium 9,000 1080
storage tank Nueva Ecija
2. 1 unit underground Brgy. San Isidro, Lupao, Unleaded 10,000 1080
storage tank Nueva Ecija
3. 1 unit underground Brgy. San Isidro, Lupao, Diesel 6,000 1080
storage tank Nueva Ecija
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
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 operating in-
house laboratory, if any

Improvement or
modification, if any.
(Description)

Cost of improvement of
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)

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 (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 Station

(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. Proof of Authority (Land Title)

√
2. Affidavit of No Complaint √

3. Vicinity Map √

4. Project/Plan Layout √

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. Complied √

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

Solid Waste Characterization/Information:

Average Quantity of Solid Total Quantity of Solid 54
Wastes Generated per 18 Wastes Generated this
month Average Quantity 54 Quarter
of Solid Wastes Total Quantity of Solid 54
Collected 18 Wastes Collected this
per month Quarter
Entity in charge of N/A
collecting solid wastes

Brief Description of To reduce the amount of solid waste, destined to disposal by preventing its generation
Solid Waste and increasing reuse, recycling, composing, and other organic materials recycling
Management Plan (e.g., methods.
waste reduction,
segregation, recycling)

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

MODULE 6: OTHERS

Accidents & Emergency Records

Findings and
Date Area/Location Actions Taken Remarks
Observation

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

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 IDs:

Name CTR No. Issued at Issued on