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    Department of Environment and Natural Resources: 3 Floor Northwing Building, DENR-XI Compound, Lanang, Davao City

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    Karen Feyt Mallari
    This document is an importation clearance form for cyanide submitted to the Environmental Management Bureau XI. It requests information from applicants seeking to import cyanide, including their contact details, existing permits, intended shipment details, present cyanide inventory, intended import volume, and a notarized certification of accurate information. Required attachments include registration certificates, environmental and discharge permits, and certifications of liability for damages from accidents. Additional documents are needed for renewal applications.

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    Department of Environment and Natural Resources: 3 Floor Northwing Building, DENR-XI Compound, Lanang, Davao City

    Uploaded by

    Karen Feyt Mallari
    67 views2 pages
    This document is an importation clearance form for cyanide submitted to the Environmental Management Bureau XI. It requests information from applicants seeking to import cyanide, including their contact details, existing permits, intended shipment details, present cyanide inventory, intended import volume, and a notarized certification of accurate information. Required attachments include registration certificates, environmental and discharge permits, and certifications of liability for damages from accidents. Additional documents are needed for renewal applications.

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    EMB XI

    Original Title

    IC-CN FORM

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    This document is an importation clearance form for cyanide submitted to the Environmental Management Bureau XI. It requests information from applicants seeking to import cyanide, including their contact details, existing permits, intended shipment details, present cyanide inventory, intended import volume, and a notarized certification of accurate information. Required attachments include registration certificates, environmental and discharge permits, and certifications of liability for damages from accidents. Additional documents are needed for renewal applications.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
    67 views2 pages

    Department of Environment and Natural Resources: 3 Floor Northwing Building, DENR-XI Compound, Lanang, Davao City

    Uploaded by

    Karen Feyt Mallari
    This document is an importation clearance form for cyanide submitted to the Environmental Management Bureau XI. It requests information from applicants seeking to import cyanide, including their contact details, existing permits, intended shipment details, present cyanide inventory, intended import volume, and a notarized certification of accurate information. Required attachments include registration certificates, environmental and discharge permits, and certifications of liability for damages from accidents. Additional documents are needed for renewal applications.

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    Republic of the Philippines

    Department of Environment and Natural Resources


    ENVIRONMENTAL MANAGEMENT BUREAU XI
    3rd
    Floor Northwing Building, DENR-XI Compound, Lanang, Davao City
    Tel. Nos. 234-0061 / 234-0166 & 233-0809 (fax)
    email address : embdavxi@yahoo.com website : emb.gov.ph/portal/r11

    IMPORTATION CLEARANCE FORM FOR CYANIDE

    Date Applied: ________________________


    Application Control Number: ____________
    Registry Reference Code: ______________
    CCO Registration #: __________________
    Date Issued: ________________________

    I. APPLICANT’S NAME: _______________________________________________________


    II. BUSINESS ADDRESS: _____________________________Contact No.: ______________
    III. STORAGE FACILITY ADDRESS: _____________________Contact No.: ______________
    IV. CONTACT PERSON: _______________________________Contact No.: ______________
    V. POSITION / DESIGNATION: _________________________FAX No.: _________________
    EMAIL ADDRESS: _________________________________
    VI. CATEGORY OF APPLICANT (IMPORTER / USER / DISTRIBUTOR): _________________
    VII. ENVIRONMENTAL AND OTHER PERMITS ISSUED:
    Permit Permit Date Issued Expiry Date Place of Issue
    Number
    Environmental
    Compliance Certificate
    Permit to Operate (Air)
    Discharge Permit
    (Effluent)
    SEC Registration
    Business Permit

    VIII. LIST OF CLIENTS / END-USER (Provide additional sheet if necessary).


    Storage Facility CCO Registration
    Name of Firm Volume Required
    Address Number

    IX. SHIPPER’S INFORMATION / TRANSACTION DATA


    COUNTRY OF ORIGIN: _______________________________________________
    NAME OF EXPORTING COMPANY: ____________________________________________
    BUSINESS ADDRESS: _______________________________________________
    MODE OF SHIPMENT (BY AIR / BY SEA): _______________________________________
    EXPECTED PORT OF ENTRY / LOADING: ______________________________________
    PORT ADDRESS: _______________________________________________
    EXPECTED DATE OF ARRIVAL: ______________________________________________

    X. PRESENT INVENTORY OF SAME SUBSTANCE (UNDER APPLICANT’S CUSTODY)


    QUANTITY (In kg): _______________ SIZE OF STORAGE AREA (In m2): _____________
    XI. VOLUME INTENDED FOR IMPORATION: _____________________________________kg.
    XII. FESS: ______________________ OR NO.: ________________ DATE: ________________

    LIST OF REQUIREMENTS / ATTACHMENTS


    󠆴 1. Accomplished and Notarized Form
    󠆴 2. Covering Letter / Endorsement Letter / Request Letter
    󠆴 3. Copy of Registration Certificate for Cyanide
    󠆴 4. ECC
    󠆴 5. Valid Waste Water Discharge Permit and Permit to Operate
    󠆴 6. Certifications for Liabilities of parties to compensate for damage to life and
    properties in case of emergencies and accidents
    ADDITIONAL REQUIREMENTS FOR RENEWAL
    󠆴 1. Bill of Lading
    󠆴 2. Summary of consumption / usage / delivery / service provided
    󠆴 3. Endorsement form from Bureau of Fishery and Aquatic Resources (BFAR)
    󠆴 4. List of registered distributors/users
    Note: For renewal application, endorsement (from BFAR) is no longer required unless there is an
    increase in importation volume where applicant has to go through CCO Registration
    Process.

    XIII. NOTARIZED CERTIFICATION


    THE UNDESIGNED CERTIFY THAT THE INFORMATION PROVIDED IN THIS FORM IS
    TRUE AND ACCURATE

    NAME : ___________________________________________
    DESIGNATION / POSITION: ___________________________________________

    SIGNATURE: __________________________ DATE: _________________

    I acknowledge that this application form is a legally binding document, and I declare under
    the penalties of perjury that the same has been accomplished in good faith, pursuant to the
    regulations issued under authority thereof.

    _______________________

    (Notary Public)

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