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 # & and Street Name: _______________________________________
Establishment/Facility
Address Barangay: __________________ City/Municipality:_____________________
(NOT the company of
head office) Province:_____________________
Name of
Owner/Company
Street # & Street Name: ________________________________
Address
(if address is not the Barangay: __________________ City/Municipality: ____________________
same as previous
address) Province: _________________________
Phone Number Fax Number
e-mail address
Type of Business/ Philippine Standard Industry Classification Code No. __________________
Industry Classification Philippine Standard Industry Descriptor: ___________________________
______________________________________________________
CEO/President: _________________________________________
Tel. #: ______________________ Fax #: _______________________
e-mail address: _______________________
Responsible Officer/s:
Plant Manager: _________________________
Tel.#: ______________________ Fax #: _______________________
e-mail address: ______________________
Pollution Control Name: _____________________________
Officer
Tel. #: __________________________ Fax #: ______________________
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
Environment Management Bureau
QUARTERLY SELF-MONITORING REPORT
Period: ___________ Month _____________ to _______________
MODULE 1: GENERAL INFORMATION
Name of Establishment
Please provide the necessary revised, corrected or updated information not contained in your
General Information Sheet
(use additional sheet if necessary)
DENR Permits/Licenses/Clearances
Environmental
Laws Permits Date of Issue Expiry Date
R.A. 9275 WDP No.
ECC 1
ECC 2
P.D. 1586
ECC 3
DENR
Registry ID
CCO Registry
R.A. 6969
Importer
Clearance No.
Permit to
Transport
R.A. 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
Maximum
Operation/Production/Capacity:
Average Daily Production Total Output this
Output Quarter
Total Water Consumption Total Electric
this Quarter (cubic meters) Consumption this
Quarter (kwH)
Please use additional sheet/s if necessary
Module 1: General Information page ____of_____
Name of Plant:
Reference No:
_________________________________________________________
MODULE 2: R.A. 6969
A. CCO Report (please accomplish this section for each chemical/substance)
Common Name/UPAC/CAS Index Name:
_______________________________________________________
______________________________ CAS No.: ____________________________
Trade Name: _____________________________________________________
For importers only:
Quantity Import Date of Arrival Quantity Port Country Country of
Requested Clearance No. Received of of Origin Manufacture
Entry
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-importers users:
Name of Client License No. 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 Chemical Total Quantity of Waste Chemical
Generated per month Generated this Quarter
Quantity of stock Inventory (Start of Quantity of stock Inventory (End
Quarter) of Quarter)
Other Information:
storage on-site treatment on-site
Manner of handling
hazardous wastes storage off-site treatment off-site
Yes (please attach copy of revise plan)
Changes in safety
management system No
Yes (please attach copy if not submitted/included in previous report/s or had been
Chemical Substitute revised)
Plan
No
Module 2A: RA 6969 (CCO Report) page ____of_____
Name of Plant:
Reference No:
_________________________________________________________
B. Hazardous Wastes Generator
HW Generation:
Remaining HW from
HW No. HW HW HW Previous Report HW Generated
Class Nature 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: _____________________________
Name: _________________________________________
Storage
Method: ___________________________________
ID: ____________________ Name: __________________________________
Transportation
Date: _________________________________________
ID: ____________________ Name: __________________________________
Treatment
Method: __________________________ Date: ___________________________
ID: ____________________ Name: __________________________________
Disposal
Date: __________________________ Date: ___________________________
HW No.: _________________________________________________
HW Details
Qty. of HW Treated: ________________________ Unit: _____________________
TSD Location: _____________________________
Name: _________________________________________
Storage
Method: ___________________________________
ID: ____________________ Name: __________________________________
Transportation
Date: _________________________________________
ID: ____________________ Name: __________________________________
Treatment
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:
Date Conducted Premises/Area Findings and Corrective Action
Inspected Observations Taken (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
Transport Storage Timetable
Type of HW Wastes Date of Permit/Date Quantity Container/ for
Wastes Number Generator Transport of Issue # of Treatment
containers
HW Treated and/or Recycled as of End of Quarter:
Type of Type &
Transport Treatment Quantity
Type of HW Wastes Date of Permit/Date Quantity or of
Wastes Number Generator Transport of Issue Recycling Recycled
Process or
Treated
Product
Residual Wastes Generated from the Treatment and/or Recycling Operation:
Process by Type of
Type of HW which the Quantity storage Disposal Timetable
Wastes Number Wastes is container/# option for Disposal
generated of
containers
Module 2C: RA 6969 (Hazardous Wastes Treater/Recycler) page ____of_____
Name of Plant:
Reference No:
_________________________________________________________
MODULE 3: R.A. 9275 (Water Pollution)
Water Pollution Data
Domestic Process wastewater
Wastewater (cubic (cubic meters/day)
meters/day)
Cooling water Others: _____________
(cubic meters/day) (cubic meters/day)
Wash water, Wash water, floor
equipment (m3/day) (cubic meters/day)
Record of Cost of Treatment
Month 1 Month 2 Month 3
New/Additional
Investments in WTP
(description)
Cost of new/add
investments
Person employed, (#
of employees)
Person employed,
(cost)
Cost of Chemicals
used by WTP
Utility costs of WTP
(electricity & water)
Administration &
Overhead costs
Cost of operating in-
house laboratory
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.
DATE Effluent BOD TSS Oil & Temp rise (name)
Flow Rate (mg/L) (mg/L) Color pH Grease (0C) _________
(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
Flow (name) (name) (name) (name) (name) (name) (name)
DATE Rate ________ ________ ________ ________ ________ ________ ________
(m3/day) (unit) (unit) (unit) (unit) (unit) (unit) (unit)
Please fill-up/accomplish separate form/s for other outlet/s.
Please use another 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 hours of operations
1.
2.
3.
4.
Fuel Burning Equipment Location # of hours of operations
1.
2.
3.
4.
5.
6.
Pollution Control Facility Location # of hours of operations
1.
2.
3.
4.
5.
Cost of Treatment
Month 1 Month 2 Month 3
Improvement or
modification, if any,
(description)
Cost of improvement
of modification
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.
Module 4: RA 8749 (Air Pollution) page ____of_____
Name of Plant:
Reference No:
_________________________________________________________
Detailed Report of Air Emission Characteristics
Description/Location
of PCF
DATE Flow Rate CO NOx Particulates (name) (name) (name) (name)
(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 (mg/Ncm) (mg/Ncm) (mg/Ncm)
(dB) (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
(mg/Ncm) (mg/Ncm) (mg/Ncm) (mg/Ncm) (mg/Ncm) (mg/Ncm) (mg/Ncm) (mg/Ncm)
(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
ECC Condition/s Compliance
Yes No Actions Taken
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
Please use additional sheet/s if necessary.
Environmental Management Plan/Program
Status of
Enhancement/Mitigation Measures Implementation
Yes No Actions Taken
1.
2.
3.
4.
5.
6.
7.
8.
Please use additional sheet/s if necessary.
Solid Waste Characterization/Information:
Average Quantity of Solid Total Quantity of Solid Wastes
Wastes Generated per month Generated this Qaurter
Average Quantity of Solid Total Quantity of 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
Date Area/Location Findings and Actions Taken Remarks
Observation
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
_________________ ______________ _________________ _________________
_________________ ______________ _________________ _________________
