CLEANUP SITE INFORMATION

CLEANUP SITE NAME BARANGAY CITY/MUNICIPALIT PROVINCE

Y

TYPE OF CLEANUP (Check one of the boxes below)

Beach River/ Inland (no Underwat Watercraft

/ Lake/ water) er
Shores Waterway

DATE OF CLEANUP MOST UNIQUE ITEMS COLLECTED

NO. OF VOLUNTEERS Total (indicate no. of each item)
WORKING ON THIS Children
(12 yrs. Old &
FORM below)

NAME OF YOUR GROUP EMAIL ADDRESS MOBILE NO.

COORDINATOR
NAME OF
SCHOOL/CLUB/ORGANIZATION/COMPANY:
NAME OF VOLUNTEERS AGE NAME OF VOLUNTEERS AGE
1. 6.
2. 7.
3. 8.
4. 9.
5. 10.
IMPORTANT TIPS: PLEASE RETURN THIS FORM IMMEDIATELY TO
YOUR AREA/ SITE COORDINATOR. YOU MAY
 Form a group with 3-5 SUBMIT RESULTS THROUGH THE FOLLOWING:
members
 Collect trash which you can EMAIL: iccphilippines@gmail.com
carry and count ONLINE: https://sites.google.com/site/iccphili
 Segregate each item first MAIL: ppines
before counting GERONIMO REYES
 Record only those listed in the ICC NATIONAL COORDINATOR
data form #3A Omega Avenue, West Fairview
 Be sure to fill-in other required Subdivision
information Brgy. West Fairview
1121 Quezon City PHILIPPINES
COUNT EACH DEBRIS ITEM LISTED USING TICK MARKS AND THEN TOTAL (Example: ////-///= 8)

CLEANUP SUMMARY ( TOTAL):

No. of
Trash Estimate (in Estimated (in
Bags d kilogram Distance kilomete
Filled: Weight: s) Cleaned: rs)

MOST LIKELY TO FIND ITEMS: FISHING GEAR:

Cigarette Butts: = Fishing Buoys, Traps: =
Fishing Net & Pieces: =
Food Wrappers =
(coffee/milk/sugar/salt/oil/vinegar/soy sachets; Rope (1 yard/meter=1 piece): =
candy, chips, biscuits, etc.):

Take Out/Away Containers (Plastic): = Fishing Line (1 yard/meter=1 piece): =

Take Out/Away Containers (Foam): = PACKAGING MATERIALS:

TOTAL #
6 – Pack Holders: =
Bottle Caps (Plastic): = Other Plastic/Foam Packaging: (shampoo, =
soap, detergent, toothpaste; fruit net,
styrofoam from appliances, etc.)
Bottle Caps (Metal): =

Lids (Plastic): = Other Plastic Bottles (oil/soy/vinegar, milk, =

bleach, detergent, shampoo, motor oil, etc.):
Straws/Stirrers: =

Forks, Knives, Spoons (plastic): = Strapping Bands: =

Beverage Bottles (Plastic) (water, softdrink) : = Tobacco/Cigarette Packaging/Wrappers: =

Beverage Bottles (Glass) (water, softdrink, = PERSONAL HYGIENE:

alcohols): TOTAL #
Condoms: =
Beverage Cans: = Syringes: =

Grocery Bags (Plastic): = Diapers: =

Other Plastic Bags: = Sanitary Napkins: =

= TINY TRASH LESS THAN 2.5 cm (size smaller

Paper Bags: than a 25 centavo coin):
TOTAL #
Cups & Plates (Paper) = Foam Pieces: =

Cups & Plates (Plastic): = Glass Pieces: =

Cups & Plates (Foam): = Plastic Pieces: =

OTHER TRASH: TOTAL # OTHER TRASH:

TOTAL #
Appliances (TV, refs, radio, computer, etc.) = Fireworks: =
(Note: whole, not pieces)
Balloons: = Tires (whole not pieces): =
Cigarette/cigar plastic tips: = Shoes/Slippers: =
Cigarette Lighters: = Toys: =
Construction Materials (wood, bars, nails, brush, = Cloth/clothing: =
etc.)(not included are bamboos & driftwoods):

LIST OF DEAD / INJURED STATUS (Dead ENTANGLED (Yes or CAUSE OF ENTANGLEMENT (line,
WILDLIFE Injured) No) net, plastics)