Professional Documents
Culture Documents
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.
Barangay
City or Municipality
Province
Type of Industry
Name of PCO
Accreditation Date
Fax No.
Legal Classification
Proprietorship
Private Corporation
Multinational
Private
Others, specify
Foreign
Government
Production
Non-Production
Number of days/month
Number of months/year
MWSS (Please
water bills)
attach
Generating Process
Process Water
Local
Water
District
(Please attach water bills)
Deep wells
Cooling
Domestic
Others
Recycled/Reuse
Others (drinking water, gardening,
evaporation,
leaks,
product
component, etc.)
Total
Volume
Wastewater
of
Discharge
No. of Bedrooms
No. of Guest/Year
Estimated Flow
(m3)
PRODUCTION INFORMATION
Product 1
Product 2
Product 3
Product Name
Actual Production
Type of Process
Batch
Continuous
Batch
Continuous
Batch
Continuous
Note: **Please use generic product name, not in brand names, in metric tons of product, carbonated drinks and beer (m3)
Except for the following substances: hog raising (heads), slaughtering/preserving
Location &
Distribution of
Outlet
Name of the
Receiving body if
not discharging in
the lake
Estimated Ave.
BOD/TSS conc.
(mg/L)
Estimated Ave.
Rate of Discharge
(m3/day)
Estimated
BOD/TSS
(kg/day)
Average Load
1
2
3
Total
______ _ ________________________
Chief Executive Officer
SUBSCRIBED 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
Doc. No.________
Page No.________
Book No.________
Series of ________