SELF-MONITORING REPORT

f o r _ _ _ Q u a r t e r, Yea r _ _ _ _
MODULE 1:

General Quality Form

ECD-PMD-017
Rev. No. 02
Effectivity Date: 04-18-2016

GENERAL INFORMATION

Name of the
Establishment /
Facility
Establishment /
Facility Address
Fax Number

Phone Number
e-mail address

CEO/President. __________________________________________________
Tel. No.: ______________________ Fax No.: _______________________
Responsible Officer/s:

e-mail address: _________________________________________________

Plant Manager: ___________________________________________________
Tel. No.: ______________________ Fax No.: _______________________
e-mail address: _________________________________________________
Name.

Pollution Control
Officer

Tel. No.: ______________________ Fax No.: _______________________

e-mail address: _________________________________________________

Legal Classification

Single Proprietorship
Private Domestic Corporation
Multi-national

Partnership
Government Corporation
Others__________________________

Permits/Licenses/Clearances
Environmental
Laws
PD 1586/ SBMA
EIS System

Permits

Date of Issue

Expiry Date

Date of Issue

Expiry Date

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

Laws
PD 1586/ SBMA
EIS System

ECC Amendment 2
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
Operating hours/day

Operating days/week

# of shift/day

Average
Maximum

Operation/Production/Capacity:
Average Daily
Production Output

Total Output this

Quarter

Total Water
Consumption this
Quarter (cubic meters)

Total Electric
Consumption this
Quarter (KwH)

(Please use additional sheet/s if necessary)

MODULE 2:
A.

RA 6969

Chemicals Used
Name
Common Name

CAS No.

Stock Inventory/Waste Chemical Generated:

Origin

Volume (Kg)/month

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

Treatment on-site

storage off-site

Treatment off-site

Changes in Safety
Management System

Yes (please attach copy of revised plan)

Chemical Substitute
Plan

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

No

No

B.

Hazardous Wastes Generator

HW Generation:
HW
No.

HW Class

HW
Nature

HW
Cataloguing

Remaining HW from
previous report
Quantity

Unit

HW Generated
Quantity

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

HW No.: _____________________________
Qty. of HW treated: _____________________

Unit __________________

Unit

TSD Location: __________________________________________________________

ID ______________________

Storage

Name: _____________________________________

Method: __________________________________
ID ______________________

Transporter

Date:_______________________

Name: _____________________________________

Date:_________________________________________________
ID ______________________

Treater

Name: _____________________________________

Method: __________________________________
ID ______________________

Disposal

Date:_______________________

Name: _____________________________________

Method: __________________________________

Date:_______________________

On-Site Self Inspection of Storage Area:

Date Conducted

MODULE 3:

Premises / Area
Inspected

Findings & Observations

Corrective Action Taken (if

any)

P.D. 984 (Water Pollution)

Water Pollution Data

Domestic wastewater
Cooling water

Wash water, equipment

_________(cu. m./day)

Process wastewater

_________(cu. m./day)

Others:

_________(cu. m./day)

Water Pollution Control facility/equipment

Sewage Treatment Plant

__ yes

___ no

Septic Tank

__ yes

___ no

Grease Trap

__ yes

___ no

Wash water, floor

_________(cu. m./day)
_________(cu. m./day)

_________(cu. m./day)

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 inhouse laboratory
New/Additional
Investments in WTP
(Description)

Cost of New/Add
Investments

WTP Discharge Location

Outlet
Number

Location of the Outlet

Name of Receiving Water Body / Outfall

1
2
3

Detailed Report of Wastewater Characteristics for Conventional Pollutants

DATE

Effluent Flow Rate

(m3/day)

BOD

TSS

Oil & Grease

Color

(mg/L)

(mg/L)

pH

Temp rise (C)

(mg/L)

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
Consumed

Fuel Used

# of hrs of
operations

1.
2.
Pollution Control Facility/Device

# of hrs of operations

1.
2.
3.

Cost of Treatment
Month 1
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 inhouse laboratory, if
any

Month 2

Month 3

Improvement or
modification, if any.
(Description)

Cost of improvement
of modification

Detailed Report of Air Emission Characteristics

Description/Location
of PCF

DATE

Flow
Rate
(Ncm/
day)

CO
(mg/Ncm)

NOx
(mg/Ncm)

Particulate
s

_______

(mg/Ncm)

(mg/Ncm)

(name)

_______
(name)
(mg/Ncm
)

_______

_______

(name)

(name)

(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
Level
(dB)

CO

NOx

Particulates

_______

_______

_______

_______

(mg/Ncm)

(mg/
Ncm)

(mg/Ncm)

(name)

(name)

(name)

(name)

(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
Yes

No

Actions Taken

1.
2.
3.
4.
5.
(Please accomplish one table per sampling station.)
Environmental Management Plan/Program

Enhancement/Mitigation Measures

Status of
Implementation
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)

Actions Taken

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

Accidents & Emergency Records

Date

Area/Location

Findings and
Observation

Actions Taken

Remarks

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