Department of Environment and Natural Resources

Environmental Management Bureau

Reference No:

(to be filled up by DENR only)

G ENER AL I NF O RM AT I O N SHEET

Name of the
Establishment/ Facility

Establishment/ Facility Street # & Street Name: _______________

Address
Barangay : _______________ City/Municipality: _______________
(NOT the company of
head office) Province : _________________

Name of Owner/
Company

Address Street # & Street Name: _______________

(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. No. _______________ Fax No. _________________
e-mail address : ______________________________
Responsible Officer/s
Plant Manager : ______________________________
Tel. No. _______________ Fax No. ______________
e-mail address: _________________________

Name : ___________________________
Pollution Control Officer Tel. No. _____________ Fax No. _______________
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 Plant Manager Name/ Signature of PCO

Module 1 General Information (___________ 20___) Page 1 of 13

Name Of Plant:
Reference No:

Department of Environment and Natural Resources

Environmental Management Bureau

QUARTERLY SELF MONITORING REPORT

1st Quarter 2nd Quarter 3rd Quarter 4th Quarter

MODULE 1: GENERAL INFORMATION

Name of the plant
Please provide the necessary revised, corrected or updated information not contained in your
General Information Sheet

Facility Address Street # & street name _________________________________

(for THW/CCO if
Barangay: ___________ City/Municipality: ________
address facility is not the
same as Plant address) Province: __

DENR Permits/Licenses/clearances
Environmental
Permits Date of issue Expiry date
Laws
A/C No.
P.D. 984
PO No.
ECC 1
PD 1586 ECC 2
ECC 3
THW Registry
ID
CCO Registry
RA 6969 Importer
registry
Permit to
transport

RA 8749 PO No.

Module 1 General Information (___________ 20___) Page 2 of 13

Name Of Plant:
Reference No:

Operation
Operating hours/day Operating days/week # of shift/day
Average
Maximum

Operation / Production / Capacity:

Average Daily Total Output this
Production Output Month
Total Water Total Electric
Consumption this Consumption this
Month (Cubic Meters) Month (kWh)
Please use additional sheet/s if necessary

Module 1 General Information (___________ 20___) Page 3 of 13

Name Of Plant:
Reference No:

MODULE 2: RA 6969

A. CCO report (please accomplish this section for each chemical /substance)

Chemical Specific Common Name/UPAC/CAS Index Name. ___

information
(Please attach 16- sections
MSDS format. If not CAS no.: __
included in previous
reports) Trade Name: ______________

For importers:
Import
Quantity Date of Quantity Country of Country of
clearance Port of entry
requested arrival received Origin Manufacture
no.

Total Quantity Total Quantity Received

Requested (annual) (annual)
* attach bill of lading

For distributors (importers/non-importers)

Name of client License no. Quantity Date of distribution

Total Quantity Distributed

For non-importer user

Name of distributor Quantity Date of purchase

Total quantity purchase from distributor

Module 2A RA 6969 (CCO Report) (________ 20__) Page 4 of 13

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 buyers Quantity Date of purchase

Total Quantity Sold

Use and production (please fill-up only if chemicals / substance is not main product)
Use daily production Total output this quarter
average
Average quantity used Total quantity used this
per month quarter
Describe any changes in production/process/operations:

Stock inventory/ waste chemical generated:

Average Quantity Of Average Quantity Of
Waste Chemical Waste Chemical
Generated Per Month Generated This Quarter
Quantity Stock Quantity Stock
Inventory (Start Of Inventory (End Of
Month/Quarter) Month/Quarter)

Other information:
Manner of handling Storage On-Site Treatment on-site
hazardous waste Storage Off-site Treatment off-site

Safety Management Yes

System (please attach a copy if not submitted/included in previous report/s or had been revised)
No
Yes
Chemical substitute (please attach a copy if not submitted/included in previous report/s or had been revised)
plan No

Module 2A RA 6969 (CCO Report) (________ 20__) Page 5 of 13

Name Of Plant:
Reference No:

B. Hazardous Wastes Generation

HW Generation:
Remaining HW from
HW HW HW generated
HW No. HW class previous report
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

ID Name
Storage
Method
ID Name
Transportation Date

ID Name
Treatment
Method Date
ID Name
Disposal
Method Date

HW no
HW details Qty of HW treated Unit
TSD location

ID Name
Storage
Method
ID Name
Transportation Date

ID Name
Treatment
Method Date
ID Name
Disposal
Method Date

Module 4: RA 8749 (Air Pollution) __________ 20__ Page 6 of 13

 Reference No:

On site inspection of storage area:

Corrective Action Taken
Date Conducted Premises Area Inspected Findings & Observations
(if any)

Has a pollution  Yes Date conducted:

management / appraisal
 No Date scheduled:
been conducted

Module 4: RA 8749 (Air Pollution) __________ 20__ Page 7 of 13

Name Of Plant:
Reference No:

C. Hazardous Waste Treater/Recycler

HW stored and/or untreated as of end of quarter

Type Of
Transport Storage Time
HW Waste Date Of
Permit/Date Valid until Quantity Container/ Table for
Number Generator Transport
Of Issue # Of Treatment
Containers

HW Treated and/or Recycled as of End of Quarter:

Type Of
Transport Storage Time
Types Of HW Waste Date Of
Permit/Date Quantity Container/ Table for
Wastes Number Generator Transport
Of Issue # Of Treatment
Containers

Residual Wastes Generated Treatment and/or Recycling Operation:

Type Of
Process
Storage
Types Of which the Disposal Time Table
HW Number Quantity Container/ #
Wastes Waste is Option for Disposal
Of
Generated
Containers

Module 4: RA 8749 (Air Pollution) __________ 20__ Page 8 of 13

Name Of Plant:
Reference No:

Module 3: P.D. 984 (Water Pollution)

Water pollution data

Domestic wastewater Process waste water
(cubic meters/day) (cubic meters/day)

Cooling water Others: _____________

(cubic meters/day) (cubic meters/day)

Wash water, equipment Wash water, floor

(m3/day) (m3/day)

Record of cost of treatment (separate entries for separate facilities)

Month 1 Month 2 Month 3
Person employed, (# of
employees)
Person employed
(Cost)
Cost of Chemicals
used by WTP
Utility cost of WTP
(electricity & water)
Administrative &
overhead cost
Cost of operating in-
house laboratory
New/Additional
investments in WTP
(Description)
Cost of New/Additional
investments

Summary of WTP

Outlet
Location of the Outlet Name Of Receiving Water Body
number
1.
2.
3.
4.
5.

Module 4: RA 8749 (Air Pollution) __________ 20__ Page 9 of 13

Name Of Plant:
Reference No:

Detailed Report of Wastewater Characteristics for Conventional Pollutants

Outlet No. 1
Effluent
Flow ___ __ ___ ___ _____ ___
Date ___
Rate (mg/L) (mg/L) (mg/L) (mg/L) (mg/L) (mg/L)
3 (mg/L)
(m /day)

Please fill-up separate form/s for other outlet/s.

Module 4: RA 8749 (Air Pollution) __________ 20__ Page 10 of 13

Name Of Plant:
Reference No:

Module 4: R.A. 8749 (Air Pollution)

Summary of APSE/APCF
Process equipment Location # of hours operations
1.
2.
3.
Fuel Burning equipment Location Fuel used Quantity # of hours
consumed (L) operation
1.
2.
3.
4.
5.
6.
7.
Pollution control facility Location # of hrs operations
1.
2.
3.

Cost of treatment
Month 1 Month 2 Month 3
Cost of person
employed, (salary)
Total consumption of
water (cubic meter)
Total cost of chemicals
used (e.g. activated
carbon , KmnO 4 )
Total consumption of
electricity (kWh)
Administrative &
overhead cost
Cost of operating in-
house laboratory
Improvement or
modification, if any.
(Description)
Cost of improvement or
modification

Module 4: RA 8749 (Air Pollution) __________ 20__ Page 11 of 13

Name Of Plant:
Reference No:

Detailed Report of Air Emission Characteristics

Description/location of
PCF

Flow Rate (Name) (Name) (Name) (Name) (Name) (Name) (Name)

Date
(Ncm/day)
(mg/Ncm) (mg/Ncm) (mg/Ncm) (mg/Ncm) (mg/Ncm) (mg/Ncm) (mg/Ncm)

Please fill-up separate form/s for other outlet/s.

Module 4: RA 8749 (Air Pollution) __________ 20__ Page 12 of 13

Module 6: OTHERS

Accidents & Emergency Records

Findings &
Date Area/Location Action Taken Remarks
Observations

Personnel/Staff Training
# of Personnel
Date conducted Course/Training Description
Trained

I hereby certify that the above information are true and correct.

Done this ________________, in ________________

Name/Signature of Acting PCO

Name/Signature of Plant
Manager

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

(___________ 20__) Page 13 of 13