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    Discharge Permit Application Form

    Uploaded by

    Rhodora Bactol Legaspi
    This document is an application form for a discharge permit from the Department of Environment and Natural Resources in the Philippines. It requests information about the applicant, their facility operations, water usage, wastewater generation and treatment systems. The form has multiple sections to provide details on employment, production processes, sources of water, wastewater outputs, treatment equipment, and a vicinity map of the facility. The applicant and pollution control officer must sign to certify that the information provided is true and accurate.

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    © All Rights Reserved
    Download as XLS, PDF, TXT or read online from Scribd

    Discharge Permit Application Form

    Uploaded by

    Rhodora Bactol Legaspi
    427 views3 pages
    This document is an application form for a discharge permit from the Department of Environment and Natural Resources in the Philippines. It requests information about the applicant, their facility operations, water usage, wastewater generation and treatment systems. The form has multiple sections to provide details on employment, production processes, sources of water, wastewater outputs, treatment equipment, and a vicinity map of the facility. The applicant and pollution control officer must sign to certify that the information provided is true and accurate.

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    dischage

    Original Title

    Discharge Permit Application Form (1)

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    This document is an application form for a discharge permit from the Department of Environment and Natural Resources in the Philippines. It requests information about the applicant, their facility operations, water usage, wastewater generation and treatment systems. The form has multiple sections to provide details on employment, production processes, sources of water, wastewater outputs, treatment equipment, and a vicinity map of the facility. The applicant and pollution control officer must sign to certify that the information provided is true and accurate.

    Copyright:

    © All Rights Reserved
    Download as XLS, PDF, TXT or read online from Scribd
    Download as xls, pdf, or txt
    427 views3 pages

    Discharge Permit Application Form

    Uploaded by

    Rhodora Bactol Legaspi
    This document is an application form for a discharge permit from the Department of Environment and Natural Resources in the Philippines. It requests information about the applicant, their facility operations, water usage, wastewater generation and treatment systems. The form has multiple sections to provide details on employment, production processes, sources of water, wastewater outputs, treatment equipment, and a vicinity map of the facility. The applicant and pollution control officer must sign to certify that the information provided is true and accurate.

    Copyright:

    © All Rights Reserved
    Download as XLS, PDF, TXT or read online from Scribd
    Download as xls, pdf, or txt
    of 3

    APPLICATION FORM FOR DISCHARGE PERMIT EPD: FORM 99-01a (Rev.

    08/21/02)

    Republic of the Philippines New


    Department of Environment and Natural Resources Renewal Expiry Date
    ENVIRONMENTAL MANAGEMENT BUREAU - NCR
    Hizon Bldg. 29, Quezon Avenue, Quezon City Application No.

    INSTRUCTION: Fill in all appropriate white spaces. Mark all appropriate boxes with an "X"
    BOX A: General Information
    Name of Applicant

    Address

    Name of Establishment TIN:

    Est. Code: Year Est.

    Plant Address No. & Street Name Barangay

    City or Municipality Region


    National Capital Region
    Type of Industry

    Name of PCO Accreditation Date

    Tel. No. & Cel.No. Fax No.:

    Legal Classification Proprietorship Private Corp. Multi-National Others: Specify

    Ownership Terms Private % Foreign % Government %

    BOX B: Employment and Operation Information

    Total employment (number of workers) in the factory: Production Non-Production

    Production Time: No. of hours/day No. of days/mo. No. of mos./year No. of days w/ discharge/mo.

    BOX C: Sources of Water Supply and Wastewater Generation

    Sources of Water Supply Monthly ave. daily ave. Generating Process Estimated Flow
    vol. (m3) vol. (m3) (m3/day)

    MWSS (please attach water bills) Process Wastewater

    Local Water District (please attach water bills) Washing/Cleaning of Process Eqpt.

    Deep Well Cooling

    Surface water (lake, river, creek, etc.) Domestic

    Others Recycled/Reuse
    Others (drinking water, gardening,
    evaporation, leaks, products components, etc.)
    Total Water Consumption Total Volume of Discharge Wastewater

    BOX D: Dwelling Units Information (hotels, condominium, restaurants, malls, etc.)

    Total Floor Area (m2) No. of Bedrooms No. of Guests/year

    Total Area for Dining Units No. of Restaurants/Dining Units

    BOX E: Product Information

    Product 1 Product 2 Product 3 Product 4

    Product Name**

    Annual Production Capacity

    Actual Production in the previous year

    Type of Process Batch Continous Batch Continous Batch Continous Batch Continous

    BOX F: Water Pollution Information


    Location & Description Name of the Receiving Body Ave. BOD, mg/L Ave. Rate of Ave. BOD Load,
    Outlet Number of the Outlet of Water Discharge, m3/day kg/day

    1
    2
    Total
    BOX G: Flow Meter Information

    Flow meter is installed at: Influent Effluent Both Total Plant Effluent None

    Type of flow meter and method used at (effluent side): Parshall Rectangular weir Triangle weir Venturi meter
    Flume

    Direct Reading Area Velocity Method

    If others, please specify device and/or method:

    BOX H: Information on the Wastewater Treatment System

    Wastewater treatment system existing? Yes No If YES, what is the capacity m3/day

    Value of capital investment in the wastewater treatment plant. Pesos

    Is there a primary treatment system? Yes No Date primary system installed : Month Year

    If Yes, what is the composition of the physical treatment system?

    Screening Equalization Grit Removal Oil-Water separation Sedimentation If others, specify


    (Flotation) (Primary Settling)

    Is there a chemical treatment? Yes No Date chemical treatment installed: Month Year

    If Yes, what is the composition of the chemical treatment system?

    Adsorption Disinfection Flocculation/coagulation pH Adjustment If others, specify

    Is there a secondary treatment system? Yes No Date installed : Month Year

    Activated Sludge Single Batch Reaction Anaerobic Digestion Oxidation/Stabilization (Pond)

    Trickling Filtration Rotating Biological Contact If others, specify

    BOX I : Vicinity Map (the map should show relative location of the establishment with respect to existing structures, landmarks, rivers, the lake and other
    water bodies, etc., use scale to fit into the frame below)

    Note: **Please use generic name. Not brand names, in metric tons of products except for the following subsectors : hog raising (heads),
    carbonated drinks and beers (m3), slaugthering/preserving meat (ton LWK, electroplating (m 2)).

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

    Name and Signature of the Pollution Control Officer Chief Executive Officer
    (Name, Signature and Position)

    SUBSCRIBED AND SWORN to before me a Notary Public, This _____ day of _________________, affiant exhibiting to me his/her Community Tax
    Receipt No. _______________________________, issued at _____________________________, on ____________________.
    NOTARY PUBLIC

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