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This document contains templates for general information and hazardous waste reporting forms required by the Department of Environment and Natural Resources of the Philippines. The general information form requests establishment details, contact information, industry classification, responsible officers, and legal classification. The hazardous waste form requires reporting of chemicals, quantities imported/distributed/used, waste generated and stored, and treatment and disposal details. It aims to monitor facilities' hazardous waste management.
This document contains templates for general information and hazardous waste reporting forms required by the Department of Environment and Natural Resources of the Philippines. The general information form requests establishment details, contact information, industry classification, responsible officers, and legal classification. The hazardous waste form requires reporting of chemicals, quantities imported/distributed/used, waste generated and stored, and treatment and disposal details. It aims to monitor facilities' hazardous waste management.
This document contains templates for general information and hazardous waste reporting forms required by the Department of Environment and Natural Resources of the Philippines. The general information form requests establishment details, contact information, industry classification, responsible officers, and legal classification. The hazardous waste form requires reporting of chemicals, quantities imported/distributed/used, waste generated and stored, and treatment and disposal details. It aims to monitor facilities' hazardous waste management.
G E N E R A L I N F O R MAT I O N ! E E T Name of the Establishment/Facility Establishment/Facility Address (NOT the company of head office) Street # & Street Name: ___ Baranay: !ity/"#nicipality: ___ $ro%ince: Name of &'ner/!ompany Address (if address is not the same as pre%io#s address) Street # & Street Name: ___ Baranay: !ity/"#nicipality: ___ $ro%ince: $hone N#mber Fa( N#mber e)mail address *ype of B#siness/ +nd#stry !lassification $hilippine Standard +nd#stry !lassification !ode No, ___ $hilippine Standard +nd#stry -escriptor: ___ ___ .esponsible &fficer/s: !E&/$resident, ___ *el #: Fa( #: ___ e)mail address: ___ $lant "anaer: ___ *el #: Fa( #: ___ e)mail address: ___ $oll#tion !ontrol &fficer Name, ___ *el #: Fa( #: ___ e)mail address: ___ /eal !lassification sinle proprietorship partnership pri%ate domestic corporation o%ernment corporation "#lti)national ___ We hereby certify that the above information are true and correct.
Name/Sinat#re of !E&/$resident Name/Sinat#re of $!& Reference No" (to be filled #p by -EN. only) Name of Plant:
Department of Environment and Natural Resources Environmental Management Bureau # $ A R T E R L% E L F & MO N I T O R I N G R E ' O R T MOD$LE (" GENERAL INFORMATION Name of the $lant $lease pro%ide the necessary re%ised0 corrected or #pdated information not contained in yo#r General Information Sheet (#se additional sheet/s if necessary) DENR 'ermits)Licenses)*learances En%ironmental /a's $ermits -ate of +ss#e E(piry -ate $,-, 123 A/! No, $& No, $- 4526 E!! 4 E!! 7 E!! 8 .A 6161 -EN. .eistry +- !!& .eistry +mporter !learance No $ermit to *ransport .A 2931 A/! No, $& No, Module 1: General Information page ____ of ____ Reference No" Name of Plant:
Operation &peratin ho#rs/day &peratin days/'ee: # of shift/day A%erae "a(im#m Operation)'roduction)*apacit+" A%erae -aily $rod#ction &#tp#t *otal &#tp#t this ;#arter *otal <ater !ons#mption this ;#arter (c#bic meters) *otal Electric !ons#mption this ;#arter (='>) $lease #se additional sheet/s if necessary Module 1: General Information page ____ of ____ Reference No" Name of Plant:
MOD$LE ," RA -.-. A/ **O Report 0please accomplis1 t1is section for eac1 c1emical)su2stance3 !ommon Name/+?$A!/!AS +nde( Name, ___ !AS No,: ___ *rade Name: ___ For importers only: ;#antity .e@#ested +mport !learance No, -ate of Arri%al ;#antity .ecei%ed A $ort of Entry !o#ntry of &riin !o#ntry of "an#fact#re *otal ;#antity .e@#ested (ann#al) *otal ;#antity .ecei%ed (ann#al) A attach copy/s of Bill of /adin For distrib#tors (importers/non)importers) Name of !lient /icense No, ;#antity -ate of -istrib#tion *otal ;#antity -istrib#ted For non)importer #sers: Name of -istrib#tor ;#antity -ate of $#rchase *otal ;#antity $#rchased from -istrib#tor For prod#cers Module 2B: RA 6969 (Hazardous astes Generator! page ____ of ____ Reference No" Name of Plant:
A%erae -aily $rod#ction &#tp#t *otal &#tp#t this ;#arter ;#antity of Stoc: +n%entory (Start of ;#arter) ;#antity of Stoc: +n%entory (End of ;#arter) Name of B#yer ;#antity -ate of $#rchase *otal ;#antity Sold $sed in 'roduction (please fill #p only if chemical/s#bstance is not main prod#ct) A%erae -aily $rod#ction &#tp#t *otal &#tp#t this ;#arter A%erae ;#antity ?sed per month *otal ;#antity ?sed this ;#arter -escribe any chanes in $rod#ction/$rocess/&perations: toc4 Inventor+)5aste *1emical Generated" A%erae ;#antity of <aste !hemical Benerated per month *otal ;#antity of <aste !hemical Benerated this ;#arter ;#antity of Stoc: +n%entory (Start of ;#arter) ;#antity of Stoc: +n%entory (End of ;#arter) Ot1er Information" "anner of handlin haCardo#s 'astes storae on)site *reatment on)site storae off)site *reatment off)site !hanes in Safety "anaement System Des (please attach copy of re%ised plan) No !hemical S#bstit#te $lan Des (please attach copy if not s#bmitted/incl#ded in pre%io#s report/s or had been re%ised) No B/ !a6ardous 5astes Generator Module 2B: RA 6969 (Hazardous astes Generator! page ____ of ____ Reference No" Name of Plant:
-ate !ond#cted $remises/Area +nspected Findins & &bser%ations !orrecti%e Action *a:en (if any) Module 2B: RA 6969 (Hazardous astes Generator! page ____ of ____ Reference No" Name of Plant:
*/ !a6ardous 5astes Treater)Rec+cler !5 tored and)or $ntreated as of End of #uarter" >< N#mber <astes Benerator -ate of *ransport *ransport $ermit/-ate of +ss#e Ealid #ntil ;#antity *ype of Storae !ontainer/ # of containers *ime *able for *reatment !5 Treated and)or Rec+cled as of End of #uarter" *ype of <astes >< N#mber <astes Benerator -ate of *ransport *ransport $ermit/-ate of +ss#e ;#antity *ype of *reatment or .ecyclin $rocess *ype & ;#antity of .ecycled or *reated $rod#ct Residual 5astes Generated from t1e Treatment and)or Rec+cling Operation" *ype of <astes >< N#mber $rocess by 'hich the <astes is Benerated ;#antity *ype of Storae !ontainer/ # of containers -isposal &ption *ime *able for -isposal Module 2": RA 6969 (Hazardous astes #reater$Re%&%ler! page ____ of ____ Reference No" Name of Plant:
MOD$LE 8" '/D/ .9: 05ater 'ollution3 5ater 'ollution Data -omestic 'aste'ater (c#bic meters/day) $rocess 'aste'ater (c#bic meters/day) !oolin 'ater (c#bic meters/day) &thers: ___________ (c#bic meters/day) <ash 'ater0 e@#ipment (m 8 /day) <ash 'ater0 floor (c#bic meters/day) Record of *ost of Treatment 0eparate entries for separate facilities3 "onth 4 "onth 7 "onth 8 $erson employed0 (# of employees) $erson employed0 (cost) !ost of !hemicals #sed by <*$ ?tility !osts of <*$ (electricity & 'ater) Administrati%e and &%erhead !osts !ost of operatin in) ho#se laboratory Ne'/Additional +n%estments in <*$ (-escription) !ost of Ne'/Add +n%estments 5T' Disc1arge Location &#tlet N#mber /ocation of the &#tlet Name of .ecei%in <ater Body 4 7 8 3 5 Module ': P()( 9*+ (ater Pollution! page ____ of ____ Reference No" Name of Plant:
Detailed Report of 5aste;ater *1aracteristics for *onventional 'ollutants &#tlet No, -A*E Effl#ent Flo' .ate (m 8 /day) B&- (m//) *SS (m//) !olor p> &il & Brease (m//) *emp rise (F!) ________ (name) (#nit) 'lease fill&up)accomplis1 separate form)s for ot1er outlet)s/ Module ': P()( 9*+ (ater Pollution! page ____ of ____ Reference No" Name of Plant:
Detailed Report of 5aste;ater *1aracteristics for Ot1er 'ollutants &#tlet No, -A*E Effl#ent Flo' .ate (m 8 /day) ________ (name) (#nit) ________ (name) (#nit) ________ (name) (#nit) ________ (name) (#nit) ________ (name) (#nit) ________ (name) (#nit) ________ (name) (#nit) 'lease fill&up)accomplis1 separate form)s for ot1er outlet)s/ 'lease use additional s1eet)s if necessar+/ Module ': P()( 9*+ (ater Pollution! page ____ of ____ Reference No" Name of Plant:
MOD$LE :" R/A/ 9<:. 0Air 'ollution3 ummar+ of A'E)A'*F $rocess E@#ipment /ocation # of hrs of operations 4, 7, 8, 3, F#el B#rnin E@#ipment /ocation F#el ?sed ;#antity !ons#med # of hrs of operations 4, 7, 8, 3, 5, 6, $oll#tion !ontrol Facility /ocation # of hrs of operations 4, 7, 8, 3, *ost of Treatment "onth 4 "onth 7 "onth 8 !ost of $erson employed0 (salary) *otal !ons#mption of <ater (c#bic meters) *otal !ost of chemicals #sed (e,,0 acti%ated carbon0 ="n&3) *otal !ons#mption of Electricity (='>) Administrati%e and &%erhead !osts !ost of operatin in) ho#se laboratory0 if any +mpro%ement or modification0 if any, (-escription) !ost of impro%ement of modification Module +: RA *,+9 (Air Pollution! page ____ of ____ Reference No" Name of Plant:
Detailed Report of Air Emission *1aracteristics -escription//ocation of $!F -A*E Flo' .ate (Ncm/day) !& (m/Ncm) N&( (m/Ncm) $artic#lates (m/Ncm) ________ (name) (m/Ncm) ________ (name) (m/Ncm) ________ (name) (m/Ncm) ________ (name) (m/Ncm) 'lease fill&up)accomplis1 separate form)s for ot1er '*F)s/ 'lease use additional s1eet)s if necessar+/ Module +: RA *,+9 (Air Pollution! page ____ of ____ Reference No" Name of Plant:
MOD$LE =" '/D/ (=9- Am2ient Air #ualit+ Monitoring 0if re>uired as part of E** conditions3 -escription//ocation of "onitorin Station -A*E Noise /e%el (dB) !& (m/Ncm ) N&( (m/Ncm ) $artic#lates (m/Ncm) ________ (name) (m/Ncm ) ________ (name) (m/Ncm ) ________ (name) (m/Ncm ) ________ (name) (m/Ncm) ($lease accomplish one table per monitorin station,) Am2ient 5ater #ualit+ Monitoring 0if re>uired as part of E** conditions3 -escription//ocation of Samplin Station -A*E ________ (name) (#nit) ________ (name) (#nit) ________ (name) (#nit) ________ (name) (#nit) ________ (name) (#nit) ________ (name) (#nit) ________ (name) (#nit) ________ (name) (#nit) ($lease accomplish one table per samplin station,) Module -: P()( 1-*6 (.I/ /&stem! page ____ of ____ Reference No" Name of Plant:
Ot1er E** *onditions E!! !ondition/s Stat#s of !ompliance Actions *a:en Des No 4, 7, 8, 3, 5, 6, 'lease use additional s1eet)s if necessar+/ Environmental Management 'lan)'rogram Enhancement/"itiation "eas#res Stat#s of +mplementation Actions *a:en Des No 4, 7, 8, 3, 5, 6, 'lease use additional s1eet)s if necessar+/ olid 5aste *1aracteri6ation)Information" A%erae ;#antity of Solid <astes Benerated per month *otal ;#antity of Solid <astes Benerated this ;#arter A%erae ;#antity of Solid <astes !ollected per month *otal ;#antity of Solid <astes !ollected this ;#arter Entity in chare of collectin solid 'astes Brief -escription of Solid <aste "anaement $lan (e,,0 'aste red#ction0 sereation0 recyclin) Module -: P()( 1-*6 (.I/ /&stem! page ____ of ____ Reference No" Name of Plant:
MOD$LE -" OT!ER Accidents ? Emergenc+ Records -ate Area//ocation Findins and &bser%ation Actions *a:en .emar:s 'ersonnel)taff Training -ate !ond#cted !o#rse/*rainin -escription # of $ersonnel *rained I hereby certify that the above information are true and correct. -one this _________________________0 in ________________________,
Name/Sinat#re of $!&
Name/Sinat#re of !E& S?BS!.+BE- AN- S<&.N before me0 a Notary $#blic0 this ________ day of ______________________0 affiants e(hibitin to me their !omm#nity *a( .eceipts: Name !*. No, +ss#ed at +ss#ed on _____________________ _____________ _______________ ______________ _____________________ _____________ _______________ ______________ Module -: P()( 1-*6 (.I/ /&stem! page ____ of ____ Reference No"