Department of Environment and Natural Resources

Environmental Management Bureau

Reference No:
(to be filled up by DENR only)

GENERAL INFORMATION SHEET

Name of the
SAM’S MOUNTAIN VIEW RIDGE HOTEL and RESORT
Establishment/Facility

Establishment/Facility Street # & Street Name: ___

Address Barangay: MARIA CLARA City/Municipality: DIFFUN
(NOT the company of head
office) Province: QUIRINO
Name of
VICENTE B. CUYOP
Owner/Company
Street # & Street Name: ___
Address
(if address is not the same as Barangay: ANDRES BONIFSCIO City/Municipality: DIFFUN___
previous address)
Province: QUIRINO

Phone Number Fax Number

e-mail address

Philippine Standard Industry Classification Code No. ___

Type of Business/
Philippine Standard Industry Descriptor: ___
Industry Classification
___

CEO/President. VICENTE B. CUYOP ______

Tel #: Fax #: ___
e-mail address: ___
Responsible Officer/s:
Plant Manager: ___
Tel #: Fax #: ___
e-mail address: ___

Name. ___
Pollution Control
Tel #: Fax #: ___
Officer
e-mail address: ___

 single proprietorship  partnership

Legal Classification  private domestic corporation  government corporation
 Multi-national  ___

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

VICENTE B. CUYOP
Name/Signature of CEO/President Name/Signature of PCO
Name of Plant:
Reference No:
___________________________________

Department of Environment and Natural Resources

Environmental Management Bureau

QUARTERLY SELF-MONITORING REPORT

MODULE 1: GENERAL INFORMATION

Name of the Plant SAM’S MOUNTAIN VIEW RIDGE HOTEL AND RESORT
Please provide the necessary revised, corrected or updated information not contained in your General
Information Sheet
Sam’s Mountainview Resort’s Discharge permits and Hazard Waste Disposal permits are on process. Hence, all
pertinent documents are being prepared to be submitted through online application. The Hotel is not yet
operational.

(use additional sheet/s if necessary)

DENR Permits/Licenses/Clearances
Environmental
Permits Date of Issue Expiry Date
Laws
RA 9275 DP No.

ECC 1 OL-RO2-2017-0038 March 10, 2017

PD 1586 ECC 2

ECC 3
DENR
Registry ID
CCO Registry
RA 6969 Importer
Clearance No
Permit to
Transport
A/C No.
RA 8749
PO No.

Module 1: General Information page ____ of ____

Name of Plant:
Reference No:
___________________________________

Operation
Operating hours/day Operating days/week # of shift/day
Average 9 hrs 63 Hrs 2 shift
Maximum 12 hrs 84 Hrs

Operation/Production/Capacity:
Average Daily
Total Output this Quarter
Production Output
Total Water Consumption Total Electric
this Quarter (cubic Consumption this Quarter
meters) (KwH)
Please use additional sheet/s if necessary

Module 1: General Information page ____ of ____

Name of Plant:
Reference No:
___________________________________

MODULE 2: RA 6969

A. CCO Report (please accomplish this section for each chemical/substance)

Common Name/IUPAC/CAS Index Name. ___

CAS No.: ___
Trade Name: ___

For importers only:

Import
Quantity Date of Quantity Country of Country of
Clearance Port of Entry
Requested Arrival Received* Origin Manufacture
No.

Total Quantity Requested Total Quantity Received

(annual) (annual)
* attach copy/s of Bill of Lading

For distributors (importers/non-importers)

Name of Client License No. Quantity Date of Distribution

Total Quantity Distributed

For non-importer users:

Name of Distributor Quantity Date of Purchase

Total Quantity Purchased from Distributor

Module 2B: RA 6969 (Hazardous Wastes Generator) page ____ of ____

Name of Plant:
Reference No:
___________________________________

For producers
Average Daily
Total Output this Quarter
Production Output
Quantity of Stock Quantity of Stock
Inventory (Start of Inventory (End of
Quarter) Quarter)
Name of Buyer Quantity Date of Purchase

Total Quantity Sold

Used in Production (please fill up only if chemical/substance is not main product)

Average Daily
Total Output this Quarter
Production Output
Average Quantity Used Total Quantity Used this
per month Quarter
Describe any changes in Production/Process/Operations:

Stock Inventory/Waste Chemical Generated:

Average Quantity of Total Quantity of Waste
Waste Chemical Chemical Generated this
Generated per month Quarter
Quantity of Stock Quantity of Stock
Inventory (Start of Inventory (End of
Quarter) Quarter)

Other Information:
Manner of handling  storage on-site  Treatment on-site
hazardous wastes  storage off-site  Treatment off-site

Changes in Safety  Yes (please attach copy of revised plan)

Management System  No

Chemical Substitute  Yes (please attach copy if not submitted/included in previous report/s or had been revised)
Plan  No

Module 2B: RA 6969 (Hazardous Wastes Generator) page ____ of ____

Name of Plant:
Reference No:
___________________________________

B. Hazardous Wastes Generator

HW Generation:
Remaining HW from
HW HW Generated
HW No. HW Class HW Nature Previous Report
Cataloguing
Quantity Unit Quantity Unit

Waste Storage, Treatment and Disposal:(Please fill-up one table per HW)
HW No,: ___
HW Details Qty of HW Treated: Unit: ___
TSD Location: ___

Name: ___
Storage
Method: ___

ID: Name: ___

Transporter
Date: ___

ID: Name: ___

Treater
Method: Date: ___

ID: Name: ___

Disposal
Date: Date: ___

HW No,: ___
HW Details Qty of HW Treated: Unit: ___
TSD Location: ___

Name: ___
Storage
Method: ___

ID: Name: ___

Transporter
Date: ___

ID: Name: ___

Treater
Method: Date: ___

ID: Name: ___

Disposal
Date: Date: ___

Module 2B: RA 6969 (Hazardous Wastes Generator) page ____ of ____

Name of Plant:
Reference No:
___________________________________

On-Site Self Inspection of Storage Area:

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

Module 2B: RA 6969 (Hazardous Wastes Generator) page ____ of ____

Name of Plant:
Reference No:
___________________________________

C. Hazardous Wastes Treater/Recycler

HW Stored and/or Untreated as of End of Quarter:

Type of
Transport Storage Time Table
Wastes Date of
HW Number Permit/Date Valid until Quantity Container/ for
Generator Transport
of Issue # of Treatment
containers

HW Treated and/or Recycled as of End of Quarter:

Type &
Type of
Transport Quantity of
Type of Wastes Date of Treatment or
HW Number Permit/Date Quantity Recycled or
Wastes Generator Transport Recycling
of Issue Treated
Process
Product

Residual Wastes Generated from the Treatment and/or Recycling Operation:

Process by Type of
Type of which the Storage Disposal Time Table for
HW Number Quantity
Wastes Wastes is Container/ Option Disposal
Generated # of containers

Module 2C: RA 6969 (Hazardous Wastes Treater/Recycler) page ____ of ____

Name of Plant:
Reference No:
___________________________________

MODULE 3: R.A. 9275 (Water Pollution)

Water Pollution Data

Domestic wastewater Process wastewater
(cubic meters/day) (cubic meters/day)
Cooling water Others: ___________
(cubic meters/day) (cubic meters/day)
Wash water, equipment Wash water, floor
(m3/day) (cubic meters/day)

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
Number
1
2
3
4
5

Module 3: R.A. 9275 (Water Pollution) page ____ of ____

Name of Plant:
Reference No:
___________________________________

Detailed Report of Wastewater Characteristics for Conventional Pollutants

Outlet No.

Effluent Oil & ________

BOD TSS Temp rise (name)
DATE Flow Rate Color pH Grease
(mg/L) (mg/L) (ºC)
(m3/day) (mg/L)
(unit)

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

Module 3: R.A. 9275 (Water Pollution) page ____ of ____

Name of Plant:
Reference No:
___________________________________

Detailed Report of Wastewater Characteristics for Other Pollutants

Outlet No.

Effluent ________ ________ ________ ________ ________ ________ ________

(name) (name) (name) (name) (name) (name) (name)
DATE Flow Rate
(m3/day)
(unit) (unit) (unit) (unit) (unit) (unit) (unit)

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

Please use additional sheet/s if necessary.

Module 3: R.A. 9275 (Water Pollution) page ____ of ____

Name of Plant:
Reference No:
___________________________________

MODULE 4: R.A. 8749 (Air Pollution)

Summary of APSE/APCF
Process Equipment Location # of hrs of operations
1.
2.
3.
4.
Fuel Burning Quantity # of hrs of
Location Fuel Used
Equipment Consumed operations
1.
2.
3.
4.
5.
6.
Pollution Control Facility Location # of hrs of operations
1.
2.
3.
4.

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, KMnO4)
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

Module 4: RA 8749 (Air Pollution) page ____ of ____

Name of Plant:
Reference No:
___________________________________

Module 4: RA 8749 (Air Pollution) page ____ of ____

Name of Plant:
Reference No:
___________________________________

Detailed Report of Air Emission Characteristics

Description/Location
of PCF
________ ________ ________ ________
Flow Rate CO NOx Particulates (name) (name) (name) (name)
DATE
(Ncm/day) (mg/Ncm) (mg/Ncm) (mg/Ncm)
(mg/Ncm) (mg/Ncm) (mg/Ncm) (mg/Ncm)

Please fill-up/accomplish separate form/s for other PCF/s.

Please use additional sheet/s if necessary.

Module 4: RA 8749 (Air Pollution) page ____ of ____

Name of Plant:
Reference No:
___________________________________

MODULE 5: P.D. 1586

Ambient Air Quality Monitoring (if required as part of ECC conditions)
Description/Location
Not applicable
of Monitoring Station
Noise ________ ________ ________ ________
CO NOx Particulates (name) (name) (name) (name)
DATE Level
(mg/Ncm) (mg/Ncm) (mg/Ncm)
(dB) (mg/Ncm) (mg/Ncm) (mg/Ncm) (mg/Ncm)

(Please accomplish one table per monitoring station.)

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

Description/Location
No analysis conducted. No effluent.
of Sampling Station
________ ________ ________ ________ ________ ________ ________ ________
(name) (name) (name) (name) (name) (name) (name) (name)
DATE
(unit) (unit) (unit) (unit) (unit) (unit) (unit) (unit)

(Please accomplish one table per sampling station.)

Module 4: RA 8749 (Air Pollution) page ____ of ____

Name of Plant:
Reference No:
___________________________________

Other ECC Conditions

Status of Compliance
ECC Condition/s Actions Taken
Yes No
1. Conduct an effective Information,
Education and Communication (IEC) Program
to inform and educate all stakeholders,
especially its contractors, workers, and local
residents about the mitigating measures
embodied in its IEEC, the conditions √ complied
stipulated in this Certificate and the
environmental and human safety features of
the project. The program shall be submitted to
EMB Regional Office on an annual basis.
2. Submit Compliance Monitoring Report
(CMR) to the EMB RO on a semiannual basis √ complied
3. All activities and areas which are
susceptible to airborne dust especially during
construction shall be managed properly to √ complied
minimize pollution.
4. Conditions 4; 7 & 9 Not applicable
5. Natural drainage should be preserved as
much as possible. Unavoidable changes in the
natural drainage shall be substituted with a √ complied
well-designed manmade canal to address
flooding.
6. Submit an environmental management
Trees (forest/fruit trees) are
program (integrated with condition no. 1 and
10) within sixty (600 days from issuance of √ planted to act as buffer
within the perimeter
this certificate.
8.Any alteration of topography which resulted
from project implementation shall consider the
recommendation of available Geological/
Geo-hazard Site Assessment Report,
otherwise the proponent should conduct its
own Geological assessment of the area and a √ complied
part of the same shall be submitted to EMB-
RO2 within ninety (90) days from completion
of the study or thirty (30) days prior to project
implementation.
10. The solid waste management scheme
which will be provided in the Environmental
Management Plan shall be implemented √ complied
immediately from the start of the construction.
11. Shall start to plant within two (2) months
from receipt of this Certificate one hundred
(100) appropriate tree species annually for a
period of five (5) years within the affected
Fenced, maintained trees,
area as part of its environmental commitment
landscaping riprap provide
and shall register the same in the National
stone masonry and the
Greening Program (NGP) of the Government. √ project is located at the
In case planting of tree is not feasible within
heart of the 25 hectare
or near the project site, the proponent shall
property of the family
coordinate with the DENR for the latter to
identify and provide / designate an area for
planting under the National Greening
Program.
12. Submit an Engineering Geological and
Geo-hazard Assessment Report (EGGAR)
within sixty (60) days from issuance of this √ complied
Certificate
13. Install billboards with a dimension two (2)
feet by four (4) feet at entry point and exit
point of the project site. The billboard shall
contained the following message:
* Title of the Project √ complied
* Location
* ECC Reference No.
* Date ECC Issued
Various plants exists like
14. The proponent shall start to plant within 2
months from receipt of this certificate….. √ mango tree, mahogany &
etc.

Module 4: RA 8749 (Air Pollution) page ____ of ____

Name of Plant:
Reference No:
___________________________________

With DP; hazard waste are

14. The proponent’s operation shall conform stored on site; Solid wastes
with the provisions of RA 6969; RA 9003; √ are recycled (Sold to
RA9275; RA 8749 junkshop) and properly
disposed
15. The proponent shall make available an
annual budget based on the project schedule. . √ Budgeted as needed
.
16. Undertake effective and community wide
Not applicable, Undertake
IEC campaign to explain publicly about the
internal IEC
project. . .
Not applicable, there are
17. Set up within 60 days from receipt hereof
only 2 workers, and they
an Environmental Unit. . .
themselves do the works.
18 In case of abandonment, a plan shall be Not applicable as of the
submitted within 1 year . . . . reporting period.
Please use additional sheet/s if necessary.

Environmental Management Plan/Program

Status of
Enhancement/Mitigation Measures Implementation Actions Taken
Yes No
Planting Trees and
1.The Land √ Landscaping in the
appropriate project area
Storm drainage canal,
2.The Water √ concrete culverts and other
flood control.
Hired qualified locals to
3.The People √ work in the project
4.The Biological Environment √ Commitment to replant trees
Regulate speed volume of
5.The Air √ vehicles within the
community
Proper maintenance of the
6.The Noise √ vehicles and facilities
Please use additional sheet/s if necessary.

Solid Waste Characterization/Information:

Average Quantity of Total Quantity of Solid
Solid Wastes Generated Wastes Generated this
per month Quarter
Average Quantity of Total Quantity of Solid
Solid Wastes Collected Wastes Collected this
per month Quarter
Entity in charge of
collecting solid wastes

Segregating the waste disposal in three (3) categories such as biodegradable,

non-biodegradable and recyclable/special waste.
Brief Description of
Solid Waste
Management Plan (e.g.,
waste reduction,
segregation, recycling)

Module 4: RA 8749 (Air Pollution) page ____ of ____

Name of Plant:
Reference No:
___________________________________

MODULE 6: OTHERS

Accidents & Emergency Records

Findings and
Date Area/Location Actions Taken Remarks
Observation

None None None None None

Personnel/Staff Training
# of Personnel
Date Conducted Course/Training Description
Trained

Fire Safety/DOLE employees & Fire safety training was conducted

employer rights by the BFP personnel Diffun and 37
Employees/employer rights was
conducted by DOLE R02

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

Done this _________________________, in ________________________.

Name/Signature of PCO
VICENTE B. CUYOP
Name/Signature of CEO

SUBSCRIBED AND SWORN before me, a Notary Public, this ________ day of
______________________, affiants exhibiting to me their Community Tax Receipts:

Name CTR No. Issued at Issued on

_____________________ _____________ _______________ ______________
_____________________ _____________ _______________ ______________

Module 4: RA 8749 (Air Pollution) page ____ of ____

 Name of Plant:
Reference No:
___________________________________

Table 1. ENVIRONMENTAL MANAGEMENT PLAN

SAM’S MOUNTAIN VIEW HOTEL AND RESORT

Project Phase/ Environmental Options for Prevention or Guarantee/Financial

Environmental Component Likely to be Potential Impact Mitigation Responsible Entity Cost Arrangements
Aspect Affected
I.Pre- A. Physical Environment
Construction
Phase
 The Land

 Survey  Change of land  Limit the area to be  Project  Cost based  Cost integrated in
revealed that some use affected by the proponent on the project
portion of the project is construction of assessment
classified as forest land facilities/ planting more of DENR-
based on its slope trees under the NGP CENRO for
category. Program SLUP
 Conduct geological
 Siting of infrastructure assessment through the
 Can cause loss  Proponent,  Cost integrated in
within hazard prone MGB and validate on
of lives / MGB, the project
area site to best suited
properties Contractors,
project location to get
Design
rid of hazard prone
Engineers, LGU
area
Diffun
 Develop a detailed
engineering design
which is most
appropriate for the
project site

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Reference No:
___________________________________

II. Construction Physical Environment

Phase
 The Land
 Soil Erosion/  The parent  Siting of the area  Proponent;  Cost integrated in
destabilization material and includes selection of Contractor; the construction
soil lesser earth movement; Environmental phase
will be  Adopt slope Unit
disturbed stabilization and
 Cost integrated in
during protection measures
 Proponent/ the project
construction of  Minimize vegetation
Contractor
facilities clearing / cut and fill
including the areas.
rehabilitation,  Provide riprap/
construction of concrete masonry  Proponent/  Based on  Cost integrated in
road networks works on disturbed Contractor detailed the project
areas engineering
design

 Degradation of the  Natural  Maintenance of  Proponent/  Cost integrated in

aesthetic and visual vegetation/ greenery and Contractor the project
effects of the area landscape landscaping in the
altered project site

 Conduct rehabilitation/  Cost integrated in

landscaping on the project
appropriate site

Module 4: RA 8749 (Air Pollution) page ____ of ____

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Reference No:
___________________________________

 The Water
 Decrease serviceability  Educate the workers to  Proponent;  Cost integrated in
of spring water due to adopt and implement Contractor; the project
utilization during proper utilization and Environmental
construction of facilities recycling of water Unit
and road network  Provision of water tank
to collect water
 Provide water for
adjacent community
who are presently
drawing water from the
same source
 Plant and maintain tree
species that can hold
supply of water
during rainy season

Module 4: RA 8749 (Air Pollution) page ____ of ____

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Reference No:
___________________________________

 Biological
Environment
1. Terrestrial Flora
and Fauna
 Vegetation clearing  Disturbance/  Recompense for loss of  Proponent  Cost integrated in
clearing of vegetation in the area Environmental the project
 Impact of vegetation natural through reforestation Unit /
removal on water vegetation program. Contractor’s
resources  Altered natural  Minimize disturbance Supervising
environment of habitat of wildlife Officer

 Impact on the  Cost integrated in

 Commitment to replant  -do-
disturbance and the project
trees/ recompense
removal of habitat to
damage vegetation thru
the biology,
a MOA with the LGU,
reproduction and
DENR re: Project’s
feeding habits of
National
wildlife

Greening Program

 Prohibit poaching of  -do-  Install signages

construction workers
 Aesthetics / Visual  Introduction of  Flora introduced can  -do-  Cost integrated in
effects flora in the site adapt the natural the project
environment

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Reference No:
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2. Air Quality  Increase of dust  Conduct regular  Proponent /  Cost integrated in

generation and sprinkling of water for Contractor the project
 Decrease air quality particulates areas affected; Control
due to of vehicle speed to
movement of lessen suspension of
vehicles / earth dust.
movement
 Increase  Regular maintenance of  Contractor /  Cost integrated in
concentration vehicles to lessen Proponent the project
of pollutant gas harmful gas emission environmental
from vehicles Unit/ LGU

 Proper maintenance of
 Increase  Proponent/
the facility
concentration Contractor
of pollutant gas
from stationary
generators

 Regulate operation of  Contractor/

 Noise  Nuisance to
facilities that will create Proponent / LGU
adjacent
nuisance
community
 Contractor/
 Abide with local Proponent
ordinances
 Cost
3. The People  Increase/influx  Hire workers from the  Proponent  Negotiation
integrated
of population locals package result
in the
due to workers should be
project
followed.
 Generation of
 Implement proper  Proponent / LGU
solid  Coordinate with
waste management
waste/construc local government
and disposal

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Reference No:
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tion debris Units/MOA

III. Operation 1. The Water

Phase  Decrease serviceability  Educate the workers to  Proponent;  Cost integrated in
of spring water due to adopt and implement Contractor; the project
utilization during proper utilization and Environmental
construction of facilities recycling of water Unit
and road network.
 Provision of water tank  -do-  Cost integrated in
to collect water the project

 Provide water for

 -do-  Cost integrated in
adjacent community
the project
who are presently
drawing water from the
same source.

 Cost integrated in
 Plant and maintain tree  -do-
the project
species that can hold
supply of water during
rainy season

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Reference No:
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2.0 The People

 Increase  Integrated  Coordinate with
 Economic Opportunity income  Giving preference to  Projects in the local officials
generation of qualified locals to work Environment project
the people in the project Unit operation

 Increase
 Install signage in
economic
 Revenue generation  -do- coordination of
activity on site
the LGU’s
 Increase
 Residual and  MOA with LGU
generation of  Implement a proper  -do-
Unavoidable Impacts solid waste waste management
and disposal in the
project area (Provide
 With budget for
MRF, segregation bins,
 -do- regular
no burning of waste)
maintenance
 ESWM Plan to be  -do-
 Introduction of
approved by LGU
disease carrying
concerned
vectors due to
poor
 Proper & Regular
maintenance of
maintenance/
swimming
sanitation of pools
pools
3.0 The Air
 Dust pollution  Install signage in
 Air Pollution due to traffic coordination of
volume the LGU’s
 Pollution from

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Reference No:
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vehicle  Regulate speed volume

emission of vehicles within the
community

 Maintenance of road
networks

 Maintenance of vehicle
 Increase noise
 Noise
level in the area
 Regulate blowing of
due to increase
horn/acceleration of
of activity/
vehicles within the
passage of
populated community
working vehicle
 With barangay /
 Increase
municipal ordinance on
nuisance due to
nuisance
presence of
recreation
facilities

Prepared by:

VICENTE B. CUYOP
Proponent

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Name of Plant:
Reference No:
___________________________________

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