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 Establishment/Facility Address
(NOT the company of head office)

Street # & Street Name: Barangay: Province: City/Municipality:

___ ___

Name of Owner/Company Address

(if address is not the same as previous address)

Street # & Street Name: Barangay: Province: Fax Number City/Municipality:

___ ___

Phone Number e-mail address

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

___ ___

CEO/President. Tel #: Responsible Officer/s: e-mail address: Plant Manager: Tel #: e-mail address: Name. Pollution Control Officer Tel #: e-mail address: single proprietorship Legal Classification private domestic corporation Multi-national partnership Fax #: ___ Fax #: ___ Fax #: ___

___ ___ ___ ___

___ ___

government corporation ___

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 the 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 P.D. 984
A/C No. PO No. ECC 1

Permits

Date of Issue

Expiry Date

PD 1586

ECC 2 ECC 3 DENR Registry ID CCO Registry

RA 6969

Importer Clearance No Permit to Transport A/C No. PO No.

RA 8749

Module 1: General Information

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Name of Plant:

Reference No:

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

Operation/Production/Capacity:
Average Daily Production Output Total Water Consumption this Quarter (cubic meters)
Please use additional sheet/s if necessary

Total Output this Quarter Total Electric Consumption this Quarter (KwH)

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)
___ CAS No.: Trade Name: ___ ___

Common Name/IUPAC/CAS Index Name.

For importers only:

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

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

Total Quantity Received (annual)

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:
Total Output this Quarter Quantity of Stock Inventory (End of Quarter) Quantity

Average Daily Production Output Quantity of Stock Inventory (Start of Quarter) Name of Buyer

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

Stock Inventory/Waste Chemical Generated:

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

Other Information:
Manner of handling hazardous wastes Changes in Safety Management System Chemical Substitute Plan storage on-site storage off-site Yes (please attach copy of revised plan) No Yes (please attach copy if not submitted/included in previous report/s or had been revised) No Treatment on-site Treatment off-site

B.

Hazardous Wastes Generator

Module 2B: RA 6969 (Hazardous Wastes Generator)

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Name of Plant:

Reference No:

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

Waste Storage, Treatment and Disposal:(Please fill-up one table per HW)
HW No,: HW Details Qty of HW Treated: TSD Location: Storage Name: Method: ID: Date: ID: Method: ID: Date: Name: Date: Name: Date: Name: Unit: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___

Transporter

Treater

Disposal

HW No,: HW Details Qty of HW Treated: TSD Location: Storage Name: Method: ID: Date: ID: Method: ID: Date: Name: Date: Name: Date: Name: Unit:

___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___

Transporter

Treater

Disposal

On-Site Self Inspection of Storage Area:

Module 2B: RA 6969 (Hazardous Wastes Generator)

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Name of Plant:

Reference No:
Corrective Action Taken (if any)

Date Conducted

Premises/Area Inspected

Findings & Observations

Module 2B: RA 6969 (Hazardous Wastes Generator)

page ____ of ____

Name of Plant:

Reference No:

C.

Hazardous Wastes Treater/Recycler

Type of Storage Container/ # of containers

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

HW Number Wastes Generator Date of Transport Transport Permit/Date of Issue Valid until Quantity Time Table for Treatment

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

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

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

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

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

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

Month 1 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 inhouse laboratory New/Additional Investments in WTP (Description) Cost of New/Add Investments Month 2 Month 3

WTP Discharge Location

Outlet Number Location of the Outlet Name of Receiving Water Body

1 2 3 4 5

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

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Name of Plant:

Reference No:

Detailed Report of Wastewater Characteristics for Conventional Pollutants

Outlet No. DATE Effluent Flow Rate (m3/day) BOD (mg/L) TSS (mg/L) Color pH Oil & Grease (mg/L) Temp rise (C) ________
(name) (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. DATE Effluent Flow Rate (m3/day) ________
(name) (unit)

________
(name) (unit)

________
(name) (unit)

________
(name) (unit)

________
(name) (unit)

________
(name) (unit)

________
(name) (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 1. 2. 3. 4. Fuel Burning Equipment 1. 2. 3. 4. 5. 6. Pollution Control Facility 1. 2. 3. 4. Location # of hrs of operations Location Fuel Used Quantity Consumed # of hrs of operations Location # of hrs of operations

Cost of Treatment
Month 1 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 inhouse laboratory, if any Improvement or modification, if any. (Description) Cost of improvement of modification Month 2 Month 3

Module 4: RA 8749 (Air Pollution)

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Name of Plant:

Reference No:

Detailed Report of Air Emission Characteristics

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

________
(name)

________
(name)

________
(name)

(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 DATE Level (dB)

CO (mg/Ncm)

NOx (mg/Ncm)

Particulates (mg/Ncm)

________
(name)

________
(name)

________
(name)

________
(name)

(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 ________ DATE
(name) (unit)

________
(name) (unit)

________
(name) (unit)

________
(name) (unit)

________
(name) (unit)

________
(name) (unit)

________
(name) (unit)

________
(name) (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

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

Status of Compliance
Yes No

Actions Taken

Environmental Management Plan/Program

Enhancement/Mitigation Measures 1. 2. 3. 4. 5. 6.
Please use additional sheet/s if necessary.

Status of Implementation
Yes No

Actions Taken

Solid Waste Characterization/Information:

Average Quantity of Solid Wastes Generated per month Average Quantity of Solid Wastes Collected per month Entity in charge of collecting solid wastes Total Quantity of Solid Wastes Generated this Quarter Total Quantity of Solid Wastes Collected this Quarter

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

Date Area/Location Findings and Observation Actions Taken Remarks

Personnel/Staff Training
Date Conducted Course/Training Description # of Personnel 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 Community Tax Receipts: Name CTR No. Issued at Issued on _____________________ _____________ _______________ ______________ _____________________ _____________ _______________ ______________

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

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