Republic of the Philippines
DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCES
ENVIRONMENTAL MANAGEMENT BUREAU
Office of the Regional Director
Region VI, Pepita Aquino Avenue, Iloilo City
Tel. No.: (033)3379801 * Telefax: (033)3369910 * Email:
[Link]
APPLICATION FOR DISCHARGE PERMIT
Application No: _______________
New
Renewal:
Permit No: _________________ Expiry Date: __ /__ /__
ECC No: ___________________
Fees Paid
Filing Fee
PD 186
Permit Fee
Wastewater Charge
Processing Fee
Amount (PhP)
Self Monitoring Report
Period Covered
SMR Submission Date
1 Qtr.
Hazardous Waste Generator ID No. ____________
O.R. No.
st
nd
Date
rd
2 Qtr.
th
3 Qtr.
4 Qtr.
INSTRUCTION: Fill in all appropriate spaces. Mark all appropriate boxes with an X. For items with numbers in
superscript, please refer to the Instructions and Directions in Accomplishing the Form under the Additional
Guidelines in Accomplishing the Form attached to this form.
NOTE:
I.
This Office will not accept an incomplete or incompletely filled-up applicable form.
General Information
Name of Establishment/Plant:
__________________________________________________________
Establishment Code ______________________ PSIC :
Description ____________________
Year Established: ________________ Capitalization: __________________ TIN: _________________________
Plant Address:
No. & Street Name: _____________________________
City or Municipality: _____________________________
Phone: _____________________________
E-mail: _____________________________
Name of PCO: _________________________________
Category of Accreditation: _______________________
Phone: _____________________________
E-mail: _____________________________
Legal Classification:
Single Proprietorship
Barangay: ____________________________________
Province: _____________________________________
Fax: _________________________________________
Accreditation No.: ______________________________
Accreditation Date: _____________________________
Fax: _________________________________________
Cell Phone: ____________________________________
Private Corporation
Partnership
Govt. Owned or Controlled Corporation Others: _______________
Ownership (%):
II.
III.
Private _____%
Local
_____%
Government _____%
Foreign
_____%
Employment and Operation Information
Number of Employees:
3
Production Workers/Service Providers : _____________________
Operating Time:
No. of hours/day
_____________________
No. of days/month
_____________________
No. of months/year
_____________________
Products/Service Information
Product/Service 1
5
Product Service Name
Unit
Rated Production Capacity
Annual Production
(projected or previous year)
Type of Process
Batch Continuous
NGO/NPO _____%
Administration : ______________________
______________________
______________________
______________________
Product/Service 2
Product/Service 3
Batch Continuous
Batch Continuous
IV.
V.
Information on non-industrial sectors such as restaurants and hotels, dwelling units, hospitals, medical,
dental and other health services, schools, and other similar establishments/ businesses
No. of customers or
Type of
Number of Days
Capacity (specific
No. of Employees
occupants or
Establishment
Operating per Year
unit __________ )
patients per year
Water Supply and Wastewater Generation
Average Water
3
Consumption (m )
Source of Water Supply
Daily
Annual
Estimated Flow (m /day)
Water Use/Sources of
Wastewater
Local Water District:
__________________
(Name of Water District)
Water
Consumed
Wastewater
Generated
Process
Washing/Cleaning
of
Process Equipment
Cooling
Domestic use such as
personal hygiene &
kitchen
Others (specify)
Deep Well
Surface Water (lake, river,
creek, etc.)
Others (specify)
Recycled/reused
for
irrigation and other
8
agricultural purposes
Total
Maximum Daily Flow
9
Rate
Total
Please submit a block diagram of the Water Balance.
VI.
QUALITY OF (ABSTRACTED) WATER SUPPLY
Sources of Water Supply
10
Average Priority Parameter Concentration (mg/L)
Heavy Metals
TSS
Oil & Grease
COD
BOD5
Local Water District:
__________________
(Name of Water District)
Deep Well
Surface Water (lake, river, creek,
etc.)
Others (specify)
11
Basis: Abstracted Water Quality
VII.
WATER POLLUTION INFORMATION
The Source ID and Outlet No. indicated below shall correspond with and match those indicated in the Sewer and
Drainage Plan and/or Drawing submitted with this application.
Source
12
ID
Discharge Outlet
No.
13
Location
Mode
Discharge
Days
(Days/Yr)
Ave. Flow
Rate
3
(m /day)
Priority Parameter Concentration (mg/L)
Outlet
No.
BOD
Influent
Effluent
TSS
Influent
Effluent
16
Oil & Grease
Effluent
Lipid/Total Mineral
Receiving Water Body
14
Name
14
Class
15
COD
Influent
Effluent
Heavy
Metal
______
Heavy
Metal
______
Effluent
Effluent
17
Outlet
No.
VIII.
BOD
Estimated Daily Average Net Waste Load (kg/day)
Heavy Metal
TSS
Oil & Grease
COD
______
FLOW MEASUREMENT INFORMATION
Outlet No.
Type of Flow Meter
Influent
IX.
WASTEWATER TREATMENT SYSTEM
Wastewater
Treatment Plant
(Name & Location)
Design Capacity
3
(m /day)
Heavy Metal
______
18
Effluent
19
Date Installed
Projected
Lifespan
(Years)
Treatment Cost (Pesos/Yr)
Capital Cost
(Depreciation)
O&M Cost
Components of Wastewater Treatment Plant/System and Treatment Efficiency (WTP-1)
Primary/Physical Treatment
Screening
Equalization
Grit Removal
Oil-water separation
Sedimentation (primary settling)
Others (specify) _____________________
20
Percent Reduction :
BOD _____ %
TSS _____ %
O&G ______%
Others (specify _______) _____ %
Chemical Treatment
pH adjustment
Disinfection
Flocculation/ Coagulation/ Precipitation
Oxidation/Reduction
Others (specify) _____________________
20
Percent Reduction :
BOD _____ %
TSS _____ %
O&G ______%
Others (specify _______) _____ %
Biological Treatment
Activated Sludge
Sequencing Batch Reactor Rotating Biological Contactor
Trickling Filter
Anaerobic Digestion
Uplflow Anaerobic Sludge Blanket (UASB) Reactor
Oxidation/Stabilization Pond
Others (specify) _____________________
20
Percent Reduction :
BOD _____ %
TSS _____ %
O&G ______%
Others (specify _______) _____ %
Components of Wastewater Treatment Plant/System and Treatment Efficiency (WTP-2)
Primary/Physical Treatment
Screening
Equalization
Grit Removal
Oil-water separation
Sedimentation (primary settling)
Others (specify) _____________________
20
Percent Reduction :
BOD _____ %
TSS _____ %
O&G ______%
Others (specify _______) _____ %
Chemical Treatment
pH adjustment
Disinfection
Flocculation/ Coagulation/ Precipitation
Oxidation/Reduction
Others (specify) _____________________
20
Percent Reduction :
BOD _____ %
TSS _____ %
O&G ______%
Others (specify _______) _____ %
Biological Treatment
Activated Sludge
Sequencing Batch Reactor Rotating Biological Contactor
Trickling Filter
Anaerobic Digestion
Upflow Anaerobic Sludge Blanket (UASB) Reactor
Oxidation/Stabilization Pond
Others (specify) _____________________
20
Percent Reduction :
BOD _____ %
TSS _____ %
O&G ______%
Others (specify _______) _____ %
Please provide additional sheets as necessary. For new application or when there is a process revision or
modification, please attach the Schematic Diagram of Treatment Process(es).
X.
Residual Management
Source
XI.
XII.
21
Type of Residual
Quantity
Disposal Method of Treatment
(Indicate disposal site, if applicable)
22
Wastewater Reuse for Irrigation and Other Agricultural Purposes
Certification
Ave. Discharge
Discharge
Type of Wastewater Reuse
3
from DA (No.)
Rate (m /day)
Days/Year
Vicinity Map
Site of Wastewater Reuse
23
I hereby certify that the above information is true and correct to the best of my knowledge. Done this ____ day of
___________ of 20 ___.
____________________________ ___
Signature over Printed Name of PCO
______________________________________
24
Signature of Printed Name of Managing Head
SUBSCRIBED AND SWORN to before a Notary Public. This ___ day of _______ of 20 ___. Affiant exhibiting to me
his/her Community Tax Certificate as follows:
Name
Community Tax
Receipt No.
Place Issued
Date Issued
NOTARY PUBLIC
Doc. No. : _____
Page No. : _____
Book No. : _____
Series of _____
