Application For Permit To Operate 2 Edit

Republic of the Philippines
Department of Environment and Natural Resources

Environmental Management Bureau
Regional Office No. III, 4/F mel-Vi Blg., O-G Road. Dolores,
City of San Fernando, Pampanga
Tel Nos. (045) 961-5206 & (045) 961-5203
APPLICATION FOR “PERMIT TO OPERATE” AIR POLLUTION SOURCE INSTALLATIONS (APSI)
Type: New/Additional Renewal Extension/Conversion

Change of Ownership Change of Name Modification/Amendment
I. General Information:
Name of Enterprises:
Address:
Name of Establishment:
Address:
TIN No: Nature of Business:
Nature of Ownership: Single Proprietorship Partnership Corporation
Authorized Capital: Paid Up Capital: Date of Start of Operation
Name of CEO: ______________________________Tel. No________________Fax No.:___________
Total Employees: Office: Production
Office Operation: hrs/day days/wk ____Production Operation: ___hrs/day ____days/wk______
2
Land Area Occupied: m Open Area: m2 Owned Leased Shared
Classification: Industrial Commercial Residential Agricultural Others
II. Raw Materials & Product Information Not Applicable

Raw Materials Quantity Products Quantity
3. List of APSI
APSI Control Facility Date Installed
(for new application)
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 Name and Signature of Chief Executive Officer
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 _.
Fees Amount Date Paid Official Receipt No.

Filing
PD 1586
Permit
Application No. ______________ Assessed by:_______________________

I NST RUCT IO NS
1. Fully accomplish this form and complete all the supporting documents indicated
hereunder. Submit all documents in triplicate to our Air Quality Management Section of the
Pollution Control Division for screening, assestment of fees, and issuance of “Order of
Payment”.
2. Pay to the Cashier Section the corresponding amount indicated in the “Order of Payment”
and present the Official Receipt to Air Quality Management Section for recording and
notation of your application.
3. Submit your application to the Records Unit and ask for your receiving copy.
Your application shall be acted upon with twenty five (25) working days and you shall be
informed of our action accordingly.
Types of Application Documents Required
 New Item Nos. , , ,  &  
 Additional/Modification Item Nos. , , ,  & 
 Change of Name/Ownership Item Nos. , ,&
 Renewal Item Nos.  & 9
Supporting Documents
 Engineer’s Report with at least containing the following:
 Description of processes including the amount of raw materials & finished products, all
the emissions into the atmosphere and or the material balance;
 List of APSI and corresponding air pollution control facility (APCF) with complete
specifications;
 Discussion of APSI & APCF showing the process/mode of operation, design criteria &
efficiencies of the APCF, the quantities & types of pollutants in the final emissions;
 Pollution loading of the regulated air pollutants in tons/year.
 Drawing requirements in 50cm x 90 cm paper signed by the President/General Manager

and duly signed and sealed by PME/ChE or any from the two.
 Vicinity Map;
 Plant & Machinery Layout showing the connection of the APSI to APCF;
 Plant & elevation drawings of each APSI & APCF.

 Copy of the Certificate of Accreditation of the Pollution Control Officer, or
appointment/designation as such by the Managing Head.
 Environmental Compliance Certificate (ECC) or Certificate of Non-Coverage (CNC) copy.

 Source Emission Test Requirement (if required).
 Copy of Recent “Permit to Operate” issued by the Office.
 Copy of SEC Registration Certificate & Articles of Incorporation.
 Copy of DTI Registration Certificate
9 Proof of compliance to permit conditiosns (if required).

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Republic of the Philippines

Department of Environment and Natural Resources

APPLICATION FOR “PERMIT TO OPERATE” AIR POLLUTION SOURCE INSTALLATIONS (APSI)

Type: New/Additional Renewal Extension/Conversion

II. Raw Materials & Product Information Not Applicable

Fees Amount Date Paid Official Receipt No.

Application No. Assessed by:_________

 Drawing requirements in 50cm x 90 cm paper signed by the President/General Manager

 Environmental Compliance Certificate (ECC) or Certificate of Non-Coverage (CNC) copy.

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