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S E L F - M O N I T O R I N G R
S E L F - M O N I T O R I N G
R E P O R T
f o r
_
Q u a r t e r,
Yea r
_
General Quality Form
ECD-PMD-017
MODULE 1:
GENERAL INFORMATION
Rev. No. 02
Effectivity Date: 04-18-2016
Name of the
Establishment /
Facility
Establishment /
Facility Address
Fax Number
Phone Number
e-mail address
__________________________________________________
Tel. No.:
Fax No.: _______________________
e-mail address: _________________________________________________
Responsible Officer/s:
Plant Manager: ___________________________________________________
Tel. No.:
Fax No.: _______________________
e-mail address: _________________________________________________
Name.
Pollution Control
Officer
Tel. No.:
Fax No.: _______________________
e-mail address: _________________________________________________
 Single Proprietorship
 Partnership
Legal Classification
 Private Domestic Corporation  Government Corporation
 Multi-national  Others __________________________

Permits/Licenses/Clearances

Environmental

Laws

Permits

Date of Issue

Expiry Date

PD 1586/ SBMA EIS System

ECC

     

ECC Amendment 1

 

Subic Bay Metropolitan Authority

 

ECOLOGY CENTER

Regulatory Building, cor. Labitan Street, Subic Bay Freeport Zone, 2222 Philippines

 

Tel: +6347 252.4435/4416

Fax: +6347 252.4157

Environmental

Permits

Date of Issue

Expiry Date

S E L F - M O N I T O R I N G R

Laws

PD 1586/ SBMA

ECC Amendment 2

EIS System

ECC Amendment 3

RA 8749

PTO No.

RA 9275

DP No.

 

DENR Registry ID

CCO Registry

RA 6969

Importer Clearance No.

     

Permit to Transport

Operation

Average

Operating hours/day

Operating days/week

# of shift/day

Maximum

Laws PD 1586/ SBMA ECC Amendment 2 EIS System ECC Amendment 3 RA 8749 RA 9275

Operation/Production/Capacity:

Average Daily Production Output

 

Total Output this Quarter

 

Total Water

 

Total Electric

 

Consumption this

Consumption this

Quarter (cubic meters)

Quarter (KwH)

(Please use additional sheet/s if necessary)

 

MODULE 2:

RA 6969

 

A.

Chemicals Used

Name

Origin

Volume (Kg)/month

Common Name CAS No.
Common Name
CAS No.

Stock Inventory/Waste Chemical Generated:

Average Quantity of Waste Chemical Generated per month

 

Total Quantity of Waste Chemical Generated this Quarter

 

Quantity of Stock Inventory (Start of Quarter)

 

Quantity of Stock Inventory (End of Quarter)

 

Other Information:

Manner of handling hazardous wastes

 

storage on-site storage off-site

Treatment on-site Treatment off-site

Changes in Safety Management System

Yes (please attach copy of revised plan)

No

Chemical Substitute Plan

Yes (please attach copy if not submitted/included in previous report/s or had been revised)

No

  • B. Hazardous Wastes Generator

HW Generation:

Remaining HW from previous report HW Generated HW HW HW HW Class No. Nature Cataloguing Quantity
Remaining HW from
previous report
HW Generated
HW
HW
HW
HW Class
No.
Nature
Cataloguing
Quantity
Unit
Quantity
Unit

Waste Storage, Treatment and Disposal: (please fill-up one table per HW)

HW Details

HW No.: _____________________________

Qty. of HW treated: _____________________

Unit __________________

 

TSD Location: __________________________________________________________

 

ID ______________________

Name: _____________________________________

Storage

Method: __________________________________

Date: _______________________

 

ID ______________________

Name: _____________________________________

Transporter

Date: _________________________________________________

 

ID ______________________

Name: _____________________________________

Treater

Method: __________________________________

Date: _______________________

 

ID ______________________

Name: _____________________________________

Disposal

Method: __________________________________

Date: _______________________

On-Site Self Inspection of Storage Area:

Date Conducted Premises / Area Inspected Findings & Observations Corrective Action Taken (if any)
Date Conducted
Premises / Area
Inspected
Findings & Observations
Corrective Action Taken (if
any)

MODULE 3:

P.D. 984 (Water Pollution)

Water Pollution Data

Domestic wastewater

_________

(cu.

m./day)

Process wastewater

_________

(cu.

m./day)

Cooling water

_________

(cu.

m./day)

Others:

_________

(cu.

m./day)

Wash water, equipment

_________

(cu.

m./day)

Wash water, floor

_________

(cu.

m./day)

Water Pollution Control facility/equipment

Sewage Treatment Plant

yes

no

Septic Tank

yes

no

Grease Trap

yes

no

 

Oil-water separator

yes

no

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 / Outfall

Number

1

2

3

Detailed Report of Wastewater Characteristics for Conventional Pollutants

DATE

Effluent Flow Rate (m 3 /day)

BOD

TSS

Color

pH

Oil & Grease

Temp rise (ºC)

(mg/L)

(mg/L)

(mg/L)

Standard
Standard

(Please fill-up/accomplish separate form/s for other outlet/s.)

MODULE 4:

R.A. 8749 (Air Pollution)

Summary of APSE/APCF

Process Equipment

# of hrs of operations

1.

.

2.

3.

Fuel Burning Equipment

 

Quantity

# of hrs of

Fuel Used

Consumed

operations

1.

2.

Pollution Control Facility/Device

 

# of hrs of operations

1.

2.

3.

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, KMnO 4 )

     

Total Consumption of Electricity (KwH)

     

Administrative and Overhead Costs

     

Cost of operating in- house laboratory, if any

     

Improvement or modification, if any.

     

(Description)

Cost of improvement of modification

     

Detailed Report of Air Emission Characteristics

Description/Location of PCF _______ _______ _______ _______ Flow Particulate CO NO x Rate s (name) DATE
Description/Location
of PCF
_______
_______
_______
_______
Flow
Particulate
CO
NO x
Rate
s
(name)
DATE
(name)
(name)
(name)
(Ncm/
(mg/Ncm)
(mg/Ncm)
(mg/Ncm)
(mg/Ncm
day)
(mg/Ncm)
(mg/Ncm)
(mg/Ncm)
)
Standard
MODULE 5:
P.D. 1586 (Philippine EIS)
Ambient Air Quality Monitoring (if required as part of ECC conditions)
Description/Location
of Monitoring Station
DATE
Noise
CO
NO x
Particulates
_______
_______
_______
_______
Level
(mg/Ncm)
(mg/
(mg/Ncm)
(name)
(name)
(name)
(name)
(dB)
Ncm)
(mg/Ncm)
(mg/Ncm)
(mg/Ncm)
(mg/Ncm)
Standard

(Please accomplish one table per monitoring station.)

Ambient Water Quality Monitoring (if required as part of ECC conditions)

Description/Location

 

of Sampling Station

DATE

_______

_______

_______

_______

_______

_______

_______

_______

(name)

(name)

(name)

(name)

(name)

(name)

(name)

(name)

(unit)

(unit)

(unit)

(unit)

(unit)

(unit)

(unit)

(unit)

 

Standard

(Please accomplish one table per sampling station.)

Other ECC Conditions

ECC Condition/s

Status of Compliance

Actions Taken

 

Yes

No

1.

2.

3.

4.

5.

(Please accomplish one table per sampling station.)

Environmental Management Plan/Program

   

Status of

 

Enhancement/Mitigation Measures

Implementation

Actions Taken

 

Yes

No

1.

2.

3.

4.

5.

(Please use additional sheet/s if necessary).

Solid Waste Characterization/Information:

Average Quantity of Solid Wastes Generated per month (Kg)

 

Total Quantity of Solid Wastes Generated this Quarter (Kg)

 

Average Quantity of Solid Wastes Collected per month (Kg)

 

Total Quantity of Solid Wastes Collected this Quarter (Kg)

 

Entity in charge of collecting solid wastes

 

Brief Description of Solid Waste Management Plan (e.g. waste reduction, segregation, recycling)

 
MODULE 6: OTHERS
MODULE 6:
OTHERS

Accidents & Emergency Records

Date

Area/Location

Findings and

Actions Taken

Remarks

Observation

         

Personnel/Staff Training

Date Conducted

Course/Training Description

# of Personnel Trained

 

I hereby certify that the above information are true and correct.

Done this

_________________________

,

in ________________________.

Name/Signature of CEO

Name/Signature of PCO