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8/12/2019 SMR FORM.doc
1/16
Department of Environment and Natural Resources
Environmental Management Bureau
G E N E R A L I N F O R M A T I O N ! E E T
Name of theEstablishment/Facility
Establishment/Facility
Address(NOTthe 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%ios address)
Street # & Street Name: ___
Baranay: !ity/"nicipality: ___
$ro%ince:
$hone Nmber Fa Nmber
email address
*ype of Bsiness/
+ndstry !lassification
$hilippine Standard +ndstry !lassification !ode No, ___
$hilippine Standard +ndstry -escriptor: ___
___
.esponsible fficer/s:
!E/$resident, ___
*el #: Fa #: ___
email address: ___
$lant "anaer: ___
*el #: Fa #: ___
email address: ___
$olltion !ontrol
fficer
Name, ___
*el #: Fa #: ___
email address: ___
eal !lassification
sinle proprietorship partnership
pri%ate domestic corporation o%ernment corporation
"ltinational ___
We hereby certify that the above information are true and correct.
Name/Sinatre of !E/$resident Name/Sinatre of $!
Reference No"
(to be filled p by -EN. only)
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Name of Plant:
Department of Environment and Natural Resources
Environmental Management Bureau
# $ A R T E R L % E L F & M O N I T O R I N G R E ' O R T
MOD$LE (" GENERAL INFORMATION
Name of the $lant
$lease pro%ide the necessary re%ised0 corrected or pdated information not contained in yor General
Information Sheet
(se additional sheet/s if necessary)
DENR 'ermits)Licenses)*learancesEn%ironmental
a's$ermits -ate of +sse Epiry -ate
$,-, 123A/! No,
$ No,
$- 4526E!! 4
E!! 7
E!! 8
.A 6161
-EN.
.eistry +-
!! .eistry
+mporter
!learance No
$ermit to
*ransport
.A 2931A/! No,
$ No,
Module 1: General Information page____ of ____
Reference No"
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Name of Plant:
Operation
peratin hors/day peratin days/'ee # of shift/day
A%erae
"aimm
Operation)'roduction)*apacit+"A%erae -aily $rodction
tpt*otal tpt this ;arter
*otal
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Name of Plant:
MOD$LE ," RA -.-.
A/ **O Report 0please accomplis1 t1is section for eac1 c1emical)su2stance3
!ommon Name/+?$A!/!AS +nde Name, ___
!AS No,: ___
*rade Name: ___
For importers only:
;antity
.e@ested
+mport
!learance
No,
-ate of
Arri%al
;antity
.ecei%ed$ort of Entry
!ontry of
riin
!ontry of
"anfactre
*otal ;antity .e@ested
(annal)
*otal ;antity .ecei%ed
(annal)
attach copy/s of Bill of adin
For distribtors (importers/nonimporters)
Name of !lient icense No, ;antity -ate of -istribtion
*otal ;antity -istribted
For nonimporter sers:
Name of -istribtor ;antity -ate of $rchase
*otal ;antity $rchased from -istribtor
For prodcers
Module 2B: RA 6969 (Hazardous astes Generator! page____ of ____
Reference No"
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Name of Plant:
A%erae -aily $rodction
tpt*otal tpt this ;arter
;antity of Stoc
+n%entory (Start of
;arter)
;antity of Stoc
+n%entory (End of
;arter)Name of Byer ;antity -ate of $rchase
*otal ;antity Sold
$sed in 'roduction (please fill p only if chemical/sbstance is not main prodct)A%erae -aily $rodction
tpt*otal tpt this ;arter
A%erae ;antity ?sed
per month
*otal ;antity ?sed this
;arter
-escribe any chanes in $rodction/$rocess/perations:
toc4 Inventor+)5aste *1emical Generated"A%erae ;antity of
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Name of Plant:
!5 Generation"
>< No, >< !lass >< Natre>< from
$re%ios .eport>< enerated
;antity ?nit ;antity ?nit
5aste torage7 Treatment and Disposal"($lease fillp one table per >< -etails
>< No0: ___
;ty of >< *reated: ?nit: ___
*S- ocation: ___
StoraeName: ___
"ethod: ___
*ransporter+-: Name: ___
-ate: ___
*reater+-: Name: ___
"ethod: -ate: ___
-isposal+-: Name: ___
-ate: -ate: ___
>< -etails
>< No0: ___
;ty of >< *reated: ?nit: ___
*S- ocation: ___
Storae
Name: ___
"ethod: ___
*ransporter+-: Name: ___
-ate: ___
*reater+-: Name: ___
"ethod: -ate: ___
-isposal+-: Name: ___
-ate: -ate: ___
On&ite elf Inspection of torage Area"
Module 2B: RA 6969 (Hazardous astes Generator! page____ of ____
Reference No"
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Name of Plant:
-ate !ondcted $remises/Area +nspected Findins & bser%ations!orrecti%e Action *aen
(if any)
Module 2B: RA 6969 (Hazardous astes Generator! page____ of ____
Reference No"
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Name of Plant:
*/ !a6ardous 5astes Treater)Rec+cler
!5 tored and)or $ntreated as of End of #uarter"
>< Nmber
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Name of Plant:
MOD$LE 8" '/D/ .9: 05ater 'ollution3
5ater 'ollution Data-omestic 'aste'ater(cbic meters/day)
$rocess 'aste'ater
(cbic meters/day)
!oolin 'ater
(cbic meters/day)
thers: ___________
(cbic meters/day)
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Name of Plant:
Detailed Report of 5aste;ater *1aracteristics for *onventional 'ollutants
tlet No,
-A*EEfflent
Flo' .ate
(m8/day)
B-
(m/)
*SS
(m/)!olor p>
il &rease
(m/)
*emp rise
(!)
________(name)
(nit)
'lease fill&up)accomplis1 separate form)s for ot1er outlet)s/
Module ': P) 9*+ (ater Pollution! page____ of ____
Reference No"
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Name of Plant:
Detailed Report of 5aste;ater *1aracteristics for Ot1er 'ollutants
tlet No,
-A*E
Efflent
Flo' .ate(m8/day)
________(name)
(nit)
________(name)
(nit)
________(name)
(nit)
________(name)
(nit)
________(name)
(nit)
________(name)
(nit)
________(name)
(nit)
'lease fill&up)accomplis1 separate form)s for ot1er outlet)s/
'lease use additional s1eet)s if necessar+/
Module ': P) 9*+ (ater Pollution! page____ of ____
Reference No"
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Name of Plant:
MOD$LE :" R/A/ 9)Administrati%e and
%erhead !osts
!ost of operatin in
hose 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"
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Name of Plant:
Detailed Report of Air Emission *1aracteristics-escription/ocation
of $!F
-A*EFlo' .ate
(Ncm/day)
!
(m/Ncm)
N(m/Ncm)
$articlates
(m/Ncm)
________(name)
(m/Ncm)
________(name)
(m/Ncm)
________(name)
(m/Ncm)
________(name)
(m/Ncm)
'lease fill&up)accomplis1 separate form)s for ot1er '*F)s/
'lease use additional s1eet)s if necessar+/
Module +: RA *,+9 (Air Pollution! page____ of ____
Reference No"
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Name of Plant:
MOD$LE =" '/D/ (=9-
Am2ient Air #ualit+ Monitoring 0if re>uired as part of E** conditions3-escription/ocation
of "onitorin
Station
-A*ENoisee%el
(dB)
!(m/Ncm
)
N(m/Ncm
)
$articlates
(m/Ncm)
________(name)
(m/Ncm
)
________(name)
(m/Ncm
)
________(name)
(m/Ncm
)
________(name)
(m/Ncm)
($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)
($lease accomplish one table per samplin station,)
Module -: P) 1-*6 (.I/ /&stem! page____ of ____
Reference No"
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Name of Plant:
Ot1er E** *onditions
E!! !ondition/sStats of !ompliance
Actions *aenDes No
4,
7,
8,
3,
5,
6,
'lease use additional s1eet)s if necessar+/
Environmental Management 'lan)'rogram
Enhancement/"itiation "easresStats of
+mplementation Actions *aenDes No
4,
7,
8,
3,
5,
6,
'lease use additional s1eet)s if necessar+/
olid 5aste *1aracteri6ation)Information"A%erae ;antity of
Solid
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Name of Plant:
MOD$LE -" OT!ER
Accidents ? Emergenc+ Records
-ate Area/ocationFindins and
bser%ation Actions *aen .emars
'ersonnel)taff Training
-ate !ondcted !orse/*rainin -escription# of $ersonnel
*rained
I hereby certify that the above information are true and correct.
-one this _________________________0 in ________________________,
Name/Sinatre of $!
Name/Sinatre of !E
S?BS!.+BE- AN- S