Republic of the Philippines

DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCES

ENVIRONMENTAL MANAGEMENT BUREAU-Region VI

2nd Flr. Pacita Salazar Bldg, EL 98 St., Jaro, Iloilo City
Tel. No.: 3001135 * Telefax: (033)5099133 * Email: embr6@yahoo.com

Application No.___________________

APPLICATION FOR PERMIT TO OPERATE

(Air Pollution Source and Control Installations)
Type: ( ) New
( ) Change of Ownership

( ) Renewal
( ) Change of Name

( ) Extension
( ) Modification

( ) Additional

1. General Information:
Name of Enterprise: _________________________________________________________________
Address: __________________________________________________________________________
Name of Establishment: ______________________________________________________________
Address: __________________________________________________________________________
TIN: ____________ Nature of Business: _________________________________________________
Nature of Ownership: ( ) Single Proprietorship ( ) Partnership
( ) Corporation
Authorized Capital: ________ Paid Up Capital: ____________ Date of Start of Operation __________
Name of CEO/Managing Head: _______________________ Tel No. _________ Fax No. __________
Total Employees: _____________ Office: _______________ Production: _______________________
Office Operation: ____ hrs/day _____ days/wk
Production Operation _______ hrs/day ____day/wk
Land Area Occupied: _____sq.m Open Area: ______ sq.m. ( ) Owned ( ) Leased ( ) Shared
Classification: ( ) Industrial ( ) Commercial ( ) Residential ( ) Agricultural ( ) ________________
2. Raw Materials & Product Information
Raw Materials

Quantity

( ) Not Applicable
Products

Quality

3. List of Air Pollution Source Installation (APSI)

(Use additional sheet if necessary)
Air Pollution Source Installation (APSI)
Control Facility
Date installed

I hereby certify that the above information are true and correct to the best of my knowledge.
Done this __________ day of _________________ 20_______.
______________________________________
Name and Signature of Pollution Control Officer

__________________________________
Chief Executive Officer/Managing Head

SUBSCRIBED and SWORN to before a Notary Public. This _____ day of _______ affiant exhibiting to me his/her
Community Tax Receipt No. ________________ issued at ______________ issued on ________________

NOTARY PUBLIC
Filing Fee: _________________ Official Receipt No. _______________ Date _______________
Permit Fee: ________________ Official Receipt No. _______________ Date _______________
P.D. 1856 _________________ Official Receipt No. _______________ Date _______________

Assessed by: ________________________________

CPD Staff

INSTRUCTIONS
1. Fully accomplish this form and complete all the supporting documents indicated hereunder.
Submit all documents in triplicate copies to our Air Quality Management Section of the Pollution
Control Division for screening, assessment of fees, and issuance of Order of Payment.
2. Pay to the Cashier Section the corresponding amount indicated in the Order of Payment and
present the Official receipt to Air Quality Management Section for recording and notation of your
application.
3. Submit your application to the Records Unit and ask for your receiving copy.
Your application shall be acted upon within twenty five (25) working days and you shall be informed of
our action accordingly.
Types of Application
New
Additional/Modification
Change of Name/Ownership
Renewal

Documents Required
Item Nos. 1, 2, 3, 4, & 5
Item Nos. 1, 2, 3, 4, & 5
Item Nos. 4, 6, 7, & 5
Item Nos. 6 & 9
Supporting Documents

1. Engineers Report with at le4ast containing the following:

Description of process including the amount of raw materials & finished products, all emissions
into the atmosphere and or the material balance;
List of APSI and corresponding Air Pollution Control Facility (APCF) with complete
specifications;
Discussion of APSI & APCF showing the process/mode of operation, design criteria &
efficiencies of the APCF, the quantities & types of pollutants in the final emissions.
Pollution loading of the regulated air pollutants in tons/year.
2. Drawing requirements in 50cm x 90cm paper signed by the President/General Manager
and duly signed and sealed by PME/ChE. Or any appropriate engineer.
Vicinity Map;
Plant & Machinery Layout showing the connection of the APSI to APCF;
Plan & Elevation drawings of each APSI & APCF.

3. Copy of the Certificate of Accreditation of the Pollution Control Officer (PCO),

appointment/ designation as such by the Managing Head;

or

4. Environmental Compliance Certificate (ECC) or Certificate of Non-Coverage (CNC) copy.

5. Source Emission Test Report (if required).

6. Copy of the recent Permit to Operate issued by the Office.

7. Copy of SEC Registration Certificate & Articles of Incorporation.

8. Copy of DTI Registration Certificate.

9. Proof of compliance to permit conditions (if required) i.e. SMR, etc