Department of Environment and Natural Resources
Environmental Management Bureau
Reference No:
(to be filled up by DENR only)
GENERAL INFORMATION SHEET
Name of the
Establishment/Facility
Establishment/Facility Street # & Street Name: _________________________
Address Barangay: _______________ City/Municipality: __________________
(NOT the company of head
office) Province:
Name of
Golden Aces Industries
Owner/Company
Street # & Street Name: ___________ ___
Address
(if address is not the same as Barangay: ____________ City/Municipality: __________
previous address)
Province:
Phone Number Fax Number
e-mail address
Philippine Standard Industry Classification Code No. ___
Type of Business/
Philippine Standard Industry Descriptor: ___
Industry Classification
___
CEO/Managing Head _____________ ___
Tel #: Fax #: __________
e-mail address: ______________________ ___
Responsible Officer/s:
Plant Manager: ________________ ___
Tel #: ________ Fax #: ___
e-mail address: _______________________ ___
Name. _______________ ___
Pollution Control
Tel #: Fax #: ___
Officer
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 Managing Head Name/Signature of PCO
Name of Plant:
Reference No:
Department of Environment and Natural Resources
Environmental Management Bureau
QUARTERLY SELF-MONITORING REPORT
MODULE 1: GENERAL INFORMATION
Name of the Plant
Please provide the necessary revised, corrected or updated information not contained in your General
Information Sheet
(use additional sheet/s if necessary)
DENR Permits/Licenses/Clearances
Environmental Laws Permits Date of Issue Expiry Date
A/C No.
P.D. 984
PO No.
ECC 1
PD 1586 ECC 2
ECC 3
DENR
Registry ID
CCO Registry
RA 6969 Importer
Clearance No
Permit to
Transport
RA 8749 PO No.
A/C No.
Module 1: General Information page ____ of ____
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 Quarter
Production Output
Total Water Consumption Total Electric
this Quarter (cubic Consumption this Quarter
meters) (KwH)
Please use additional sheet/s if necessary
Module 1: General Information page ____ of ____
Name of Plant:
Reference No:
MODULE 2: RA 6969
A. CCO Report (please accomplish this section for each chemical/substance)
Common Name/IUPAC/CAS Index Name. ___
CAS No.: ___
Trade Name: ___
For importers only:
Import
Quantity Date of Quantity Country of Country of
Clearance Port of Entry
Requested Arrival Received* Origin Manufacture
No.
Total Quantity Requested Total Quantity Received
(annual) (annual)
* attach copy/s of Bill of Lading
For distributors (importers/non-importers)
Name of Client License No. Quantity Date of Distribution
Total Quantity Distributed
For non-importer users:
Name of Distributor Quantity Date of Purchase
Total Quantity Purchased from Distributor
Module 2B: RA 6969 (Hazardous Wastes Generator) page ____ of ____
Name of Plant:
Reference No:
For producers
Average Daily
Total Output this Quarter
Production Output
Quantity of Stock Quantity of Stock
Inventory (Start of Inventory (End of
Quarter) Quarter)
Name of Buyer Quantity Date of Purchase
Total Quantity Sold
Used in Production (please fill up only if chemical/substance is not main product)
Average Daily
Total Output this Quarter
Production Output
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 Total Quantity of Waste
Waste Chemical Chemical Generated this
Generated per month Quarter
Quantity of Stock Quantity of Stock
Inventory (Start of Inventory (End of
Quarter) Quarter)
Other Information:
Manner of handling storage on-site Treatment on-site
hazardous wastes storage off-site Treatment off-site
Changes in Safety Yes (please attach copy of revised plan)
Management System No
Chemical Substitute Yes (please attach copy if not submitted/included in previous report/s or had been revised)
Plan No Hazardous Wastes Generator
Module 2B: RA 6969 (Hazardous Wastes Generator) page ____ of ____
Name of Plant:
Reference No:
B.
HW Generation:
Remaining HW from
HW HW Generated
HW No. HW Class HW Nature Previous Report
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: ________ ___
Name: _______________ ___
Storage
Method: _________ ___
ID: ____________ Name: ____________________________________ ___
Transporter
Date: _________ ___
ID: Name: ______________________________________________
Treater
Method: Date: ___
ID: ________ Name: ___________________________________
Disposal
Date: Date: ___
HW No,: _______________ ___
HW Details Qty of HW Treated: _____________ Unit: ___ ___
TSD Location: _________________ ___
Name: ____________________________________________________________
Storage
Method: ____________________________________________________________
ID: _____________ Name: ____ ___
Transporter
Date: ___
ID: _________ Name: _________________________
Treater
Method: ______________ Date: ___
ID: _ Name: ________________ ___
Disposal
Date: Date: _____________________ ___
Module 2B: RA 6969 (Hazardous Wastes Generator) page ____ of ____
Name of Plant:
Reference No:
On-Site Self Inspection of Storage Area:
Corrective Action Taken
Date Conducted Premises/Area Inspected Findings & Observations
(if any)
Module 2B: RA 6969 (Hazardous Wastes Generator) page ____ of ____
Name of Plant:
Reference No:
C. Hazardous Wastes Treater/Recycler
HW Stored and/or Untreated as of End of Quarter:
Type of
Transport Storage Time Table
Wastes Date of
HW Number Permit/Date Valid until Quantity Container/ for
Generator Transport
of Issue # of Treatment
containers
HW Treated and/or Recycled as of End of Quarter:
Type &
Type of
Transport Quantity of
Type of Wastes Date of Treatment or
HW Number Permit/Date Quantity Recycled or
Wastes Generator Transport Recycling
of Issue Treated
Process
Product
Residual Wastes Generated from the Treatment and/or Recycling Operation:
Process by Type of
Type of which the Storage Disposal Time Table for
HW Number Quantity
Wastes Wastes is Container/ Option Disposal
Generated # of containers
Module 2C: RA 6969 (Hazardous Wastes Treater/Recycler) page ____ of ____
Name of Plant:
Reference No:
MODULE 3: P.D. 984 (Water Pollution)
Water Pollution Data
Domestic wastewater Process wastewater
(cubic meters/day) (cubic meters/day)
Cooling water Others: ___________
(cubic meters/day) (cubic meters/day)
Wash water, equipment Wash water, floor
(m3/day) (cubic meters/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 Costs of WTP
(electricity & water)
Administrative and
Overhead Costs
Cost of operating in-
house laboratory
New/Additional
Investments in WTP
(Description)
Cost of New/Add
Investments
WTP Discharge Location
Outlet
Location of the Outlet Name of Receiving Water Body
Number
1
2
3
4
5
Module 3: P.D. 984 (Water Pollution) page ____ of ____
Name of Plant:
Reference No:
Detailed Report of Wastewater Characteristics for Conventional Pollutants
Outlet No.
Effluent Oil & ________
BOD TSS Temp rise (name)
DATE Flow Rate Color pH Grease
(mg/L) (mg/L) (ºC)
(m3/day) (mg/L)
(unit)
Please fill-up/accomplish separate form/s for other outlet/s.
Module 3: P.D. 984 (Water Pollution) page ____ of ____
Name of Plant:
Reference No:
Detailed Report of Wastewater Characteristics for Other Pollutants
Outlet No.
Effluent ________ ________ ________ ________ ________ ________ ________
(name) (name) (name) (name) (name) (name) (name)
DATE Flow Rate
(m3/day)
(unit) (unit) (unit) (unit) (unit) (unit) (unit)
Please fill-up/accomplish separate form/s for other outlet/s.
Please use additional sheet/s if necessary.
Module 3: P.D. 984 (Water Pollution) page ____ of ____
Name of Plant:
Reference No:
MODULE 4: R.A. 8749 (Air Pollution)
Summary of APSE/APCF
Process Equipment Location # of hrs of operations
1.
2. none
3.
4.
Fuel Burning Quantity # of hrs of
Location Fuel Used
Equipment Consumed operations
1.
2.
3.
4.
5.
6.
Pollution Control Facility Location # of hrs of operations
1.
2.
3.
4.
Cost of Treatment
Month 1 Month 2 Month 3
Cost of Person employed,
(salary)
Total Consumption of
Water (cubic meters)
Total Cost of chemicals
used (e.g., activated
carbon, KMnO4)
Total Consumption of
Electricity (KwH)
Administrative and
Overhead Costs
Cost of operating in-
house laboratory, if any
Improvement or
modification, if any.
(Description)
Module 4: RA 8749 (Air Pollution) page ____ of ____
Name of Plant:
Reference No:
Cost of improvement of
modification
Module 4: RA 8749 (Air Pollution) page ____ of ____
Name of Plant:
Reference No:
Detailed Report of Air Emission Characteristics
Description/Location
of PCF
________ ________ ________ ________
Flow Rate CO NOx Particulates (name) (name) (name) (name)
DATE
(Ncm/day) (mg/Ncm) (mg/Ncm) (mg/Ncm)
(mg/Ncm) (mg/Ncm) (mg/Ncm) (mg/Ncm)
N/A
Please fill-up/accomplish separate form/s for other PCF/s.
Please use additional sheet/s if necessary.
Module 4: RA 8749 (Air Pollution) page ____ of ____
Name of Plant:
Reference No:
MODULE 5: P.D. 1586
Ambient Air Quality Monitoring (if required as part of ECC conditions)
Description/Location
of Monitoring
Station
Noise ________ ________ ________ ________
CO NOx Particulates (name) (name) (name) (name)
DATE Level
(mg/Ncm) (mg/Ncm) (mg/Ncm)
(dB) (mg/Ncm) (mg/Ncm) (mg/Ncm) (mg/Ncm)
(Please accomplish one table per monitoring station.)
Ambient Water Quality Monitoring (if required as part of ECC conditions)
Description/Location
of Sampling Station
________ ________ ________ ________ ________ ________ ________ ________
(name) (name) (name) (name) (name) (name) (name) (name)
DATE
(unit) (unit) (unit) (unit) (unit) (unit) (unit) (unit)
(Please accomplish one table per sampling station.)
Module 5: P.D. 1586 (EIS System) page ____ of ____
Name of Plant:
Reference No:
Other ECC Conditions
Status of Compliance
ECC Condition/s Actions Taken
Yes No
1.
2.
3.
4.
5.
6.
Please use additional sheet/s if necessary.
Environmental Management Plan/Program
Status of
Enhancement/Mitigation Measures Implementation Actions Taken
Yes No
1.
2.
3.
4.
5.
6.
Please use additional sheet/s if necessary.
Solid Waste Characterization/Information:
Average Quantity of Total Quantity of Solid
Solid Wastes Generated Wastes Generated this
per month Quarter
Average Quantity of Total Quantity of Solid
Solid Wastes Collected Wastes Collected this
per month Quarter
Entity in charge of
collecting solid wastes
Brief Description of
Solid Waste
Management Plan (e.g.,
waste reduction,
segregation, recycling)
Module 5: P.D. 1586 (EIS System) page ____ of ____
Name of Plant:
Reference No:
MODULE 6: OTHERS
Accidents & Emergency Records
Findings and
Date Area/Location Actions Taken Remarks
Observation
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 Managing Head Name/Signature of PCO
Module 5: P.D. 1586 (EIS System) page ____ of ____
Name of Plant:
Reference No:
SUBSCRIBED AND SWORN before me, a Notary Public, this ________________
of _______________, affiants exhibiting to me their Community Tax Receipts:
Name CTR No. Issued at Issued on
_____________________ _____________ _______________ ______________
_____________________ _____________ _______________ ______________
Module 5: P.D. 1586 (EIS System) page ____ of ____
