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EPD: FORM 99-01a (Rev.08/21/02)

Republic of the Philippines New

Renewal

Philippine Sugar Center Building, North Avenue, Diliman, Quezon City Application No.:

http://www.llda.gov.ph | info@llda.gov.ph

INSTRUCTION: Fill in all appropriate white spaces. Mark all appropriate boxes with an "X" TIN:: enera n orma on

Name of Establishment/Plant Est. Code: Year Est.

Plant Address No. & Street Name Barangay

City or Municipality Province

Type of Industry

Name of PCO Accreditation Date

Tel. No. & Cel.No. Fax No.:

Legal Classification Proprietorship Private Corp. Multi-National Others: Specify

Ownership Terms Private % Foreign % Government %

BOX B: Employment and Operation Information

Total employment (number of workers) in the factory: Production Non-Production

Production Time: No. of hours/day No. of days/mo. No. of mos./year

BOX C: Sources of Water Supply and Wastewater Generation

MWSS (please attach water bills) Process Wastewater

Local Water District (please attach water bills) Washing/Cleaning of Process Eqpt.

Deep Well Cooling

Surface water (lake, river, creek, etc.) Domestic

Others Recycled/Reuse

Others (drinking water, gardening,

evaporation, leaks, products components, etc.)

Total Water Consumption Total Volume of Discharge Wastewater

: we ng n s n orma on o es, con omn um, res auran s, ma s, e c.

Total Floor Area (m2) No. of Bedrooms No. of Guests/year

Total Area for Dining Units No. of Restaurants/Dining Units

BOX E: Product Information

Product Name**

Annual Production Capacity

Actual Production in the previous year

Type of Process Batch Continous Batch Continous Batch Continous Batch Continous

: a er o u on n orma on

1

2

3

Total

Product 4

Estimated Flow

(m /day)

Generating Process

APPLICATION FORM FOR DISCHARGE PERMIT

Sources of Water Supply

Expiry Date

No. of days w/ discharge/mo.

Monthly ave.

vol. (m3) vol. (m3)

Product 1 Product 2

LAGUNA LAKE DEVELOPMENT AUTHORITY

(kg/day)

Outlet Number

Location & Description

of the Outlet

Name of the Receiving Body if

NOT Discharging Directly in

the Lake

Estimated Average

BOD Load

Estimated

Average BOD

Conc.

(mg/L)

Estimated Average

Rate of Discharge

(m3/day)

daily ave.

Product 3

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BOX G: Flow Meter Information

Flow meter is installed at: Influent Effluent Both Total Plant Effluent None

Type of flow meter and method used at (effluent side): Parshall Rectangular weir Triangle weir Venturi meter

Flume

Direct Reading Area Velocity Method

If others, please specify device and/or method:

BOX H: Information on the Wastewater Treatment System

Wastewater treatment system existing? Yes No If YES, what is the capacity m /day

Value of capital investment in the wastewater treatment plant. Pesos

Is there a primary treatment system? Yes No Date primary system installed : Month Year

If Yes, what is the composition of the physical treatment system?

Screening Equalization Grit Removal Oil-Water separation Sedimentation If others, specify

(Flotation) (Primary Settling)

Is there a chemical treatment? Yes No Date chemical treatment installed: Month Year

If Yes, what is the composition of the chemical treatment system?

Adsorption Disinfection Flocculation/coagulation pH Adjustment If others, specify

Is there a secondary treatment system? Yes No Date installed : Month Year

Activated Sludge Single Batch Reaction Anaerobic Digestion Oxidation/Stabilization (Pond)

Trickling Filtration Rotating Biological Contact If others, specify

BOX I : Vicinity Map (the map should show relative location of the establishment with respect to existing structures, landmarks, rivers, the lake and other

water bodies, etc., use scale to fit into the frame below)

Note: **Please use generic name. Not brand names, in metric tons of products except for the following subsectors : hog raising (heads),

carbonated drinks and beers (m ), slaugthering/preserving meat (ton LWK, electroplating (m )).

I hereby certify that the above information are true and correct to the best of my knowledge. Done this ___________________ day of

________________, ________.

Name and Signature of the Pollution Control Officer

SUBSCRIBED AND SWORN to before me a Notary Public, This _____ day of _________________, affiant exhibiting to me his/her Community Tax

Receipt No. _______________________________, issued at _____________________________, on ____________________.

Chief Executive Officer

(Name, Signature and Position)

NOTARY PUBLIC