Self Monitoring Report
Self Monitoring Report
G E N E R AL I N F O R M ATI O N S H E E T
Name of the
Establishment/Facility
Establishment/Facility
Address
(NOT the company of head
office)
Name of
Owner/Company
Address
(if address is not the same
as previous address)
___
Barangay:
City/Municipality:
___
Province:
Phone Number
Fax Number
e-mail address
Type of Business/
Industry
Classification
___
___
___
Fax #:
e-mail address:
___
___
Fax #:
e-mail address:
___
___
Tel #:
Fax #:
___
Legal Classification
single proprietorship
partnership
government corporation
Multi-national
We hereby certify that the above information are true and correct.
ENGR. JOSE REY S. BATOMALAQUE
Name/Signature of CEO/President
ROMIL C. PAMINTUAN
Name/Signature of PCO
___
Name of Plant:
Reference No:
GENERAL INFORMATION
DENR Permits/Licenses/Clearances
Environmental
Laws
P.D. 984
Permits
Expiry Date
A/C No.
PO No.
ECC 1/CNC
PD 1586
Date of Issue
N/A
ECC 2
ECC 3
DENR
Registry ID
RA 6969
CCO Registry
Importer
Clearance No
Permit to
Transport
Name of Plant:
RA 8749
Reference No:
A/C No.
PO No.
Name of Plant:
Reference No:
Operation
Operating hours/day
Operating days/week
# of shift/day
8 HRS
6 DAYS
3 SHIFT
Average
Maximum
Operation/Production/Capacity:
Average Daily
Production Output
Total Water
Consumption this
Quarter (cubic meters)
50 MT
3900 MT
Name of Plant:
Reference No:
MODULE 2:
A.
RA 6969
___
CAS No.:
___
Trade Name:
___
Quantity
Requested
Date of
Arrival
Quantity
Received*
Total Quantity
Requested (annual)
* attach copy/s of Bill of Lading
Port of
Entry
Country of
Origin
Country of
Manufacture
Total Quantity
Received (annual)
License No.
Quantity
Date of Distribution
Quantity
Date of Purchase
For producers
Name of Plant:
Reference No:
Average Daily
Production Output
Quantity of Stock
Inventory (Start of
Quarter)
Name of Buyer
Date of Purchase
Other Information:
Manner of handling
hazardous wastes
storage on-site
Treatment on-site
storage off-site
Treatment off-site
Changes in Safety
Management System
Chemical Substitute
Plan
Yes (please attach copy if not submitted/included in previous report/s or had been revised)
No
No
Name of Plant:
B.
Reference No:
HW Generation:
HW No.
HW Class
HW Nature
Remaining HW from
Previous Report
Quantity
Unit
HW
Cataloguin
g
HW Generated
Quantity
Unit
Waste Storage, Treatment and Disposal:(Please fill-up one table per HW)
HW No,:
HW Details
Storage
Transporter
Treater
Disposal
___
Qty of HW Treated:
Unit:
TSD Location:
___
Name:
___
Method:
___
ID:
Name:
___
Date:
ID:
___
Name:
Method:
ID:
___
Date:
___
Name:
Date:
___
Date:
___
HW No,:
HW Details
Storage
Transporter
Treater
Disposal
___
___
Qty of HW Treated:
Unit:
___
TSD Location:
___
Name:
___
Method:
___
ID:
Name:
___
Date:
ID:
___
Name:
Method:
ID:
___
Date:
Name:
Date:
___
___
Date:
___
Name of Plant:
Reference No:
Premises/Area
Inspected
Findings &
Observations
Name of Plant:
C.
Reference No:
Wastes
Generator
Date of
Transport
Transport
Permit/Date
of Issue
Valid until
Quantity
Type of
Storage
Container/
# of
containers
Time Table
for
Treatment
Quantity
Type of
Treatment
or
Recycling
Process
Type &
Quantity of
Recycled
or Treated
Product
HW
Number
Wastes
Generator
Date of
Transport
Transport
Permit/Date
of Issue
HW Number
Process by
which the
Wastes is
Generated
Quantity
Type of
Storage
Container/
# of
containers
Disposal
Option
Time Table
for Disposal
Name of Plant:
MODULE 3:
Reference No:
Process wastewater
(cubic meters/day)
Others: ___________
(cubic meters/day)
Wash water, floor
(cubic meters/day)
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 inhouse laboratory
New/Additional
Investments in WTP
(Description)
Cost of New/Add
Investments
1
2
3
4
5
SEPTIC TANK
Name of Plant:
Reference No:
Effluent
Flow Rate
(m3/day)
BOD
(mg/L)
TSS
(mg/L)
Color
pH
Oil &
Grease
(mg/L)
Temp rise
(C)
________
(name)
(unit)
Name of Plant:
Reference No:
Outlet No.
DATE
Effluent
Flow Rate
(m3/day)
________
________
________
________
________
________
________
(name)
(name)
(name)
(name)
(name)
(name)
(name)
(unit)
(unit)
(unit)
(unit)
(unit)
(unit)
(unit)
Name of Plant:
MODULE 4:
Reference No:
R.A. 8749 (Air Pollution)
Summary of APSE/APCF
Process Equipment
Location
# of hrs of operations
1.
2.
3.
4.
Fuel Burning
Equipment
Location
Fuel Used
Quantity
Consumed
# of hrs of
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 inhouse laboratory, if any
Improvement or
modification, if any.
(Description)
Cost of improvement of
modification
Name of Plant:
Reference No:
Flow Rate
(Ncm/day)
CO
(mg/Ncm)
NOx
(mg/Ncm)
Particulates
(mg/Ncm)
________
(name)
(mg/Ncm)
_______
_
_______
_
(name)
(name)
(mg/Ncm)
(mg/Ncm)
________
(name)
(mg/Ncm)
Name of Plant:
Reference No:
MODULE 5:
P.D. 1586
Noise
Level (dB)
CO
(mg/Ncm)
NOx
(mg/Ncm)
Particulates
(mg/Ncm)
________
(name)
(mg/Ncm)
_______
_
_______
_
(name)
(name)
(mg/Ncm)
(mg/Ncm)
________
(name)
(mg/Ncm)
________
________
________
________
________
________
________
(name)
(name)
(name)
(name)
(name)
(name)
(name)
(name)
(unit)
(unit)
(unit)
(unit)
(unit)
(unit)
(unit)
(unit)
Name of Plant:
Reference No:
Status of Compliance
Yes
Actions Taken
No
COMPLIED
COMPLIED
3.SMR
COMPLIED
4.
5.
6.
7.
Please use additional sheet/s if necessary.
Status of
Implementation
Yes
Actions Taken
No
1.PROPER HOUSEKEEPING
IMPLEMENTED
2.PPE
IMPLEMENTED
3. TREE PLANTING
IMPLEMENTED
4.
5.
6.
7.
Please use additional sheet/s if necessary.
Brief Description of
Solid Waste
Management Plan
(e.g., waste reduction,
segregation, recycling)
2 PER MONTH
2 PER MONTH
6 IN 3 MONTHS
6 IN 3 MONTHS
OTHERS
Findings and
Observation
Area/Location
Actions Taken
Remarks
NO ACCIDENT
HAPPENED
FOR THE
PAST 3
MONTHS
Personnel/Staff Training
Date Conducted
Course/Training Description
# of Personnel
Trained
I hereby certify that the above information are true and correct.
Done this _________________________, in ________________________.
ROMIL C. PAMINTUAN
Name/Signature of PCO
ENGR.JOSE REY S. BATOMALAQUE
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
_____________________ _____________ _______________ ______________
_____________________ _____________ _______________ ______________
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