Professional Documents
Culture Documents
Fees Paid
Filing Fee
PD 186
Permit Fee
Wastewater Charge
Processing Fee
Amount (PhP)
1 Qtr.
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:
__________________________________________________________
Description ____________________
Single Proprietorship
Barangay: ____________________________________
Province: _____________________________________
Fax: _________________________________________
Accreditation No.: ______________________________
Accreditation Date: _____________________________
Fax: _________________________________________
Cell Phone: ____________________________________
Private Corporation
Partnership
II.
III.
Private _____%
Local
_____%
Government _____%
Foreign
_____%
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 Use/Sources of
Wastewater
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
10
BOD5
Discharge Outlet
No.
13
Location
Mode
Discharge
Days
(Days/Yr)
Ave. Flow
Rate
3
(m /day)
BOD
Influent
Effluent
TSS
Influent
Effluent
16
Effluent
Lipid/Total Mineral
Name
14
Class
15
COD
Influent
Effluent
Heavy
Metal
______
Heavy
Metal
______
Effluent
Effluent
17
Outlet
No.
VIII.
BOD
IX.
Design Capacity
3
(m /day)
Heavy Metal
______
18
Effluent
19
Date Installed
Projected
Lifespan
(Years)
O&M Cost
X.
Residual Management
Source
XI.
XII.
21
Type of Residual
Quantity
22
Vicinity Map
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 _____