Republic of the Philippines

Department of Environment and Natural Resources

ENVIRONMENTAL MANAGEMENT BUREAU
Region VII, Banilad, Mandaue City
Telephone: 3469426 / 3453905 Fax: 3461647

APPLICATION FORM FOR PERMIT TO OPERATE

New 

Renewal  Expiry Date Permit No.

INSTRUCTION:
1. This form shall be fully accomplished in duplicate copies and required documents completed; otherwise, application will be
returned.
2. This application must be accompanied with transmittal/cover letter addressed to the Regional Director.

Name & Position of Applicant : ____________________________________________________________________

Name of Firm : ____________________________________________________________________
Address (Plant) : ____________________________________________________________________
Tel. No. : ____________________________________________________________________
Name of Pollution Control Officer : ____________________________________________________________________
General Nature of Business : ____________________________________________________________________
Pollution Source and Control : (If renewal, attach copies of latest permits, emission test; SMR’s PCO Accreditation;
if new, or modification of source(s) submit engineering report, plans & specifications
of APSEs & its APCD; air quality impact analysis & vicinity map, emission test as
provided in Rule XIX, Sec. 5 of DAO 2000-81.
Others: (Information on new sources): Increase in pollution load, change of APCD, change of raw materials, etc.

Air Pollution Sources Information:

Consumption of
No./Type of Equipment Kind of fuel fuel li/day or Capacity of APCD Chimney
kg./day Height

Source Specific Air Pollutants Compliance/Non-compliance Information:

Nature & Maximum Compliance
Name of Capacity of Pollutant Standard Applicable to Source Permissible Emission Test Emission
APSE APCD Limits Results Estimate
(mg/Ncm)
Antimony and its compounds Any source 10 as Sb
Arsenic and its compounds Any source 10 as As
Cadmium & its compounds Any source 10 as Cd
Carbon Monoxide Any industrial source 500 as CO
Copper and its compounds Any industrial source 100 as Cu
Hydrofluoric Acid and Fluoride Any source other than 50 as HF
compounds manufacture of Aluminum from
Alumina
Hydrogen Sulfide i) Geothermal power plants c, d
ii) Geothermal Exploration
and Well Testing e
iii) Any source other than (i)
and (ii) 7 as H2S
Lead Any trade, industry or process 10 as Pb
Mercury Any source 5 as elemental
Hg
Nickel and its compounds except Any source 20 as Ni
Nickel Carbonylf
NOX 1) Manufacture of Nitric 2,000 as acid &
Acid NO2
2) Fuel burning steam calculated as
generators NO2
a) Existing Source 1,500 as NO2
b) New Source
 i) Coal-fired 1,000 as NO2
ii) Oil-fired 500 as NO2
3) Diesel-powered 2,000 as NO2
electricity generators
4) Any source other than
(1), (2) and (3)
a) Existing Source 1,000 as NO2
b) New Source 500 as NO2
Particulates 1) Fuel burning equipment
a) Urbang and industrial 150
Areah
b) Other areai 200
2) Cement Plants (kilns, 150
etc.)
3) Smelting Furnaces 150
4) Other Stationary 200
Sourcesj
Phosphorous Pentoxidek Any source 200 as P2O5
Sulfur Oxides 1) Existing Sources
a) Manufacture of Sulfuric 2,000 as SO3
Acid and Sulf(on)ation 1,500 as SO2
Process 1,000 as SO3
b) Fuel Burning Equipment 1,500 as SO3
c) Other Stationary Sources
2) New Sources
a) Manufacture of Sulfuric 700 as SO2
Acid and Sulf(on)ation 200 as SO3
Process
b) Fuel Burning Equipment
c) Other Stationary Sources
Zinc and its Compounds Any Source 100 as Zn

Third Party Emission Test Information:

Name of Party conducting Test:
Name of Laboratory Performing Analysis:
Address of laboratory:
Date of Sampling: Date of Analysis:
Method of Sampling:
Previous commitments for non-compliance
Present status of APSE/APCD

I hereby certify that the above information are true and correct to the best of my knowledge. Done this ________ day of
______________________ of ______________.

_________________________________________ _________________________________
Name and Signature of the Pollution Control Officer Chief Executive Officer

Filing Fee Official Receipt Number: _____________________ Amount Php: ________________

P.D. 1856 Official Receipt Number: _____________________ Amount Php: ________________

SUBSCRIBE AND SWORN to before a Notary Public this _______ day of _________________________. Affiant exhibiting to
me his/her Community Tax Receipt No. ________ issued.

NOTARY PUBLIC