Discharge Permit Application Form Sample Filled Up dz3g

 Republic of the Philippines   Department of Environment and Natural Resources                    ENVIRONMENTAL MANAGEMENT BUREAU                    Regional Office No. III   

APPLICATION FORM FOR DISCHARGE PERMIT New Renewal

Expiry Date: ________________

TIN

Application Number: ___________________________________ INSTRUCTION: Fill in all complete white spaces. Mark all appropriate boxes with an ‘X’. Note: Failure to complete this form may be sufficient ground for disapproval of the Permit Application

General Information Name of the Establishment/Plant: ____________________________________________________ Est. Code: ______________________ Year EST: ______________________ Plant Address: No. & Street Name: _________________ Barangay: ___________________________ City/Municipality: __________________ Province: ___________________________ Telephone No: _____________________ Fax No: _____________________________ Type of Industry: __________________________________ Name of PCO: ____________________________________ Accreditation Date: ______________

Legal Classification Ownership

Proprietorship:

□

Private: ______%

Private Corp:

□

Foreign: ______%

Multi-National:

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Government: ______%

Employment and Operation Information Total Employment (number of workers) in the factory: ________________

□

Production Production Time:

□

Non-Production Number of hrs/day: ______ Number of days/mo: ______ Number of mos/yr: ______

Sources of Water and Wastewater Generation Sources of Water Monthly Daily Supply Ave. Ave. Vol. (m3) Vol.(m3) MWSS (pls. attach water bills) Local Water District (pls. attach water bills) Deep well Surface Water (lake, river, creek, etc.) Others

Total Water Consumption

Generating Process

Estimated Flow (m3/day)

Washing/Cleaning of Process Equipment Washing/Cleaning of Process Equipment Cooling Domestic Recycled/Reused Others (drinking water, gardening, evaporation, leaks, product component, etc.) Total Volume of Discharge Wastewater

Dwelling Units Information (hotels, condominiums, restaurants, malls, etc.) Total Floor Area (m2): __________ No. of Bedrooms: __________ No. of Guests/yr: _________ Total Area/Dining Units: ________ No. of Restaurants/Dining Units: _________

 Republic of the Philippines   Department of Environment and Natural Resources                    ENVIRONMENTAL MANAGEMENT BUREAU                    Regional Office No. III   

Product Information Product 1 Product Name Actual Production Capacity Actual Production in the previous years Type of Process

□ Continuous □ Batch

Product 2

□ Continuous □

Batch

Product 3

Product 4

□ Continuous □

□ Continuous □

Batch

Batch

Note: Please use generic product name, not brand names, in metric tons of products except for the substances: hog-raising (heads), carbonated drinks and beers (m3), slaughtering/preserving of meat (ton LWK), electroplating (m2) Water Pollution Information Outlet Location and Number of Number Distribution of Receiving Body of the Outlet Water if not discharging directly to the lake 1 2 3 Total

Estimated Ave. BOD/TSS Concentration (mg/L)

Estimated Ave. Rate of Discharge (m3/day)

Estimated Ave. BOD/TSS Load (kg/day)

Name of Laboratory Performing Analysis Address of Laboratory

Date of Sampling

Date of Analysis

Method of Sampling

Vicinity Map (The map should show relative location of the establishment with respect to existing structures, landmarks, rivers and other waterbodies, etc. Use scale to fit in the frame below.)

Fixed Fee Official Receipt Number

I hereby certify that above information are true and correct to the best of my knowledge. Done this __________ day of __________ 20_____.

___________________________________

____________________

Name and Signature of Pollution Control Officer

Chief Executive Officer

SUBSCRIBE AND SWORN to before a Notary Public. This __________ day of ____________Affiant exhibiting to me his/her Community Tax Receipt No._____________ issued at ___________________.