Republic of the Philippines
DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCES
ENVIRONMENTAL MANAGEMENT BUREAU
Office of the Regional Director
Region IX, Western Mindanao
Lantawan Pasonanca, Zamboanga City
 (062) 992-7156
Application for Discharge Permit
New
Renewal
Expiry Date
TIN
Application No.
INSTRUCTION: Fill in all appropriate white spaces. Mark all appropriate boxes with an “X”.
NOTE: Failure to complete this form may be sufficient ground for disapproval of the permit application.
GENERAL INFORMATION:
Name of Establishment/Plant:
Est. Code:
Year Est. .
Plant Address No. & Street Name
Barangay:
City or Municipal:
Province:
Type of Industry:
Name of PCO
Accreditation Date:
Tel. No. & Cel. No.
Fax No.
Legal Classification
Proprietorship
Private Corporation
Ownership Terms (%)
private
Multinational
%
Others: Specify
Foreign
%
Government
%
EMPLOYMENT AND OPERATION INFORMATION
Total Employment (number of workers) in the factory:
Production Time: Number of Hours/day
Production
Non-Production
Number of days/month
Number of months/year
SOURCES OF WATER SUPPLY AND WASTEWATER GENERATION
Sources of Water Supply
Monthly Ave. Daily Ave.
Vol. (m3)
Vol. (m3)
Generating Process
MWSS (Please attach water bills)
Process water
Local Water District (Please attach
Water bills)
Washing/Cleaning of Process equipment
Deep Wells
Cooling
Surface water(lakes, river,creek, etc.)
Others
Domestic
Recycled/reused
Others (drinking water, gardening, evaporation
Leaks, product component, etc.)
Total Water Consumption
Total Volume of Discharge Wastewater
Dwellings Units Information (hotels, condiminium, restaurants, malls, etc)
Total floor area (m2)
Total Area for dwelling Unit (m2)
No. of bedrooms
No of Restaurants/dining unit
No of Guest/year
Estimated flow
(m3/day)
PRODUCTION INFORMATION
Product 1
Product 2
Product 3
Product Name
Actual Production
Actual Production in the
Previous Year
Type of Process
Batch
Continuous
Batch
Continuous
Batch
Continuous
3
Note: **Please use generic product name, not in brand names, in metric tons of product, carbonated drinks and beer (m )
except for the following substances: hog raising(heads) slaughtering/preserving
Water Pollution Information
Outlet
Number
1
Location & Distribution of the Name of the Receiving
Outlet
body if not Discharging
In the lake.
Estimated Ave. Estimated Ave.
Estimated
BOD/TSS conc. Rate of Discharge BOD/TSS
(mg/l)
(m3/day)
(kg/day)
Average
Load
2
3
Name of Laboratory performing Analysis:
Address of Laboratory:
Date of Sampling :
Method of Sampling :
Total
Date of Analysis
Vicinity Map (The map should show relative location of the establishment with respect to existing structures, landmarks, rivers, lakes and
Other water bodies, etc..Use scale to fit into the frame below.
Fixed Fee Official Receipt Number:_____________________ Date of issue__________________
I hereby certify that the above information are true and correct to the best of my knowledge. Done this _________day of_________________
of 20______________.
_________________________________________________
Name and Signature of the Pollution Control Officer
_______________________________________________
Chief Executive Officer
SUBSCRIBE AND SWORN to before a Notary Public. This __________ day of ____________________.Affiant exhibiting to me his/her
Community Tax Receipt NO._________________Issued at _______________________ on______________________.
NOTARY PUBLIC
REQUIREMENTS FOR APPLICATION FOR A WASTEWATER DISCHARGE PERMIT
FOR NEW APPLICATION
a) Engineer’s Report containing such information as:
i)
ii)
iii)
iv)
v)
vi)
vii)
viii)
ix)
x)
xi)
xii)
xiii)
xiv)
Vicinity map identifying the street address, location or plant premises;
The nature of project or business;
Production capacity; quantity or volume and the generic name(s) of product(s)
The nature and character of the applicant’s wastewater and its physical and chemical
composition;
Total daily volume of discharge of raw wastewater;
Treatment process and estimated treatment efficiency;
The total daily volume of water consumption and discharge of final treated wastewater or
effluent
The name of receiving body of water and its official water classification and in case of
land discharge, the nearest receiving body of water and its official water classification;
Information on flow measurement equipment and procedure;
Pollution prevention/Environmental System plan of program;
DENR ID Number as hazardous waste generator (if applicable)
Statement of the cost incurred in the installation and maintenance of wastewater
treatment facility, if any;
Quality and quantity of abstracted water; and
Copy of Environmental Compliance Certificate (ECC) from the Department of
Certificate of Non-Coverage (CNC), as applicable.
A registered chemical or sanitary engineer or Pollution Control Officer shall sign such engineer
report concurred by the Managing Head.
FOR RENEWAL OF DISCHARGE PERMITS
b) A copy of the quarterly self-monitoring report for the immediately preceding year.
c) A copy of the Certificate of Accreditation of the Pollution Control Officer duly issued by the department, or
appointment/designation as such by the Managing Head;
d) Official receipt for the payment of the applicable Fixed fee; and
e) Other documents that may be required related to land application
Failure to submit the necessary requirements shall be sufficient ground for the disapproval of application.