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
Street # & Street Name:
Establishment/Facility Address
Barangay:
(NOT the company of head office)
City/Municipality: Province:
Name of Owner/Company
Address Street # & Street Name:
(if address is not the same as Barangay:
previous address) City/Municipality: Province:
Phone Number Fax Number
e-mail address
Philippine Standard
Type of Business/ Industry
Classification Industry Classification
Code No. PSIC
CEO/President.
Tel #: ______Fax #: _____e-mail address:
Responsible Officer/s:
Plant Manager:
Tel #: ______Fax #: _____e-mail address:
Name.
Pollution Control Officer
Tel #: ______Fax #: _____e-mail address:
Legal Classification single proprietorship
partnership
private domestic corporation
government corp.
Multi-national
Name/Signature of CEO/President Name/Signature of PCO
We hereby certify that the above information are true and correct.
Name of Plant:
Reference No:
Department of Environment and Natural
Resources Environmental Management
Bureau
Q U A R T E R LY S E LF - M O N I T O R I N G R E P O R T
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 Date of Expiry
Permits
Laws Issue Date
P.D. 984 A/C No.
PO No.
PD 1586 ECC 1
ECC 2
ECC 3
RA 6969 DENR Registry ID
CCO Registry
Importer Clearance No
Permit to Transport
RA 8749 A/C No.
PO No.
Module 1: General Information page of
Name of Plant: Reference No:
Operation
Operating Operating # of shift/day
hours/day days/week
Average
Maximum
Operation/Production/Capacity:
Total Output this
Average Quarter
Daily
Production
Output
Total Water Total Electric
Consumption this Consumption this
Quarter (cubic Quarter (KwH)
meters)
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. ____________________________
CAS No.:_________________ Trade Name:
For importers only:
Import
Quantity Date of Quantity Country of Country of
Requested Clearance Arrival Received* Port of 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 2B: RA 6969 (Hazardous Wastes Generator) page of
Name of Plant: Reference No:
For producers
Average Daily
Total Output this Quarter
Production Output
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 Quarter
Production Output
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 Total Quantity of
Waste Chemical Waste Chemical
Generated per month Generated this 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
Yes (please attach copy if not submitted/included in
Chemical Substitute previous report/s or had been revised)
Plan
No
Name of Plant: Reference No:
B Hazardous Wastes Generator
.
HW Generation:
Remaining HW
from Previous HW Generated
HW HW HW Report
HW No. Cataloguing
Class Nature
Quantity Unit Quantity Unit
Waste Storage, Treatment and Disposal:
(Please fill-up one table per HW)
HW Details HW No,:
Qty of HW Treated: Unit: TSD
Location:
Storage
Name:
Method:
Transporter
ID: Name: Date:
Treater ID: Name:
Method: Date:
Disposal ID: Name:
Date: Date:
On-Site Self Inspection of Storage Area:
Corrective Action
Premises/Area Findings &
Date Conducted Taken
Inspected 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
Time
Trans Storage
Date Table
HW Waste Permit/ Valid Contai
of Qty for
Number s Gen. Date of until ner/
Trans Treatm
Issue # of
ent
contain
ers
HW Treated and/or Recycled as of End of Quarter:
Type &
Type of
Transpo Quantit
Type Waste Date Treatme
rt y of
of HW s of Quantit nt or
Permit/ Recycle
Wast Number Genera Transp y Recyclin
Date of d or
es tor ort g
Issue Treated
Process
Product
Residual Wastes Generated from the Treatment and/or Recycling Operation:
Type of
Storage
Type Process by
Contain Dispos Time Table
of HW which the
Qty er/ al for
Waste Number Wastes is
# of Option Disposal
s Generated
container
s
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
(cubic meters/day) (cubic meters/day)
Cooling water (cubic Others: (cubic
meters/day) meters/day)
Wash water, equipment Wash water, floor
3
(m /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
Number Body
1
2
3
Module 3: P.D. 984 (Water Pollution) page of
Name of Plant:
Reference No:
Detailed Report of Wastewater Characteristics for Conventional Pollutants
Outlet No.
DATE Efflue BOD TSS Color pH Oil Temp (name)
nt (mg/L) (mg/L) & rise
Flow Grea (ºC) (unit)
Rate se
(m3/da (mg/
y) L)
Please fill-up/accomplish separate form/s for other outlet/s.
Detailed Report of Wastewater Characteristics for Other Pollutants
Outlet No.
DATE Efflue (name) (name) (name) (name) (name) (name) (name)
nt
Flow (unit) (unit) (unit) (unit) (unit) (unit) (unit)
Rate
(m3/da
y)
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.
2.
Fuel
Fuel Quantity # of hrs of
Burning Location
Used Consumed operations
Equipment
1.
2.
Pollution Control Facility Location # of hrs of
operations
1.
2.
scrubbers, dust collectors, thermal oxidizers, cyclones, blowers, mist collectors, catalytic converters and
electrostatic precipitators
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 Particul (name) (name) (name) (name)
CO NOx
Rate ates
DATE (mg/ (mg/N
(Ncm/ (mg/Nc (mg/ (mg/ (mg/ (mg/
Ncm) cm)
day) m) Ncm) Ncm) Ncm) 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
Particula (name) (name) (name) (name)
Noise NOx
DATE Level CO tes
(mg/Nc
(dB) (mg/Ncm) m) (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
ECC Condition/s Status of Actions Taken
Compliance
Yes No
1.
2.
3.
Please use additional sheet/s if necessary.
Environmental Management Plan/Program
Status of
Enhancement/Mitigation Implementation
Actions Taken
Measures
Yes No
1.
2.
3.
Please use additional sheet/s if necessary.
Solid Waste Characterization/Information:
Total Quantity of
Average Quantity of Solid Solid Wastes
Wastes Generated per month Generated this
Quarter
Total Quantity of
Average Quantity of Solid Solid Wastes
Wastes Collected per month Collected this
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
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 Community Tax Receipts:
Name CTR No. Issued at Issued on
Module 5: P.D. 1586 (EIS System) page of
