LAGUNA LAKE DEVELOPMENT AUTHORITYNational Ecology Center, East Avenue

Diliman, Quezon CityTel. Nos.: 332-2346, 376-4039, 376-4072, 376-4049, 376-4061

APPLICATION FOR DISCHARGE PERMITNEW RENEWAL REVALIDATION Expiry Date of latest DP: ____________

A. APPLICANT INFORMATIONName of Establishment/Project:_________________Tax Identification Number (TIN): ________________________ Year Established: ____________________Location of Establishment/Project:

Number and Street: _______________________City/Municipality: ________________________ Province: _____________________________Tel. # :_______________________________ Fax #: ___________________________________

Business Activity: __________________________________________________________Applicant’s Pollution Control Officer:

Name: ____________________________________Cert. of Accreditation No.:_______________________Cel. #: ________________________________email add: __________________________________________

B. Employment and Operation InformationTotal Employment (number of workers) Operational Schedule/Time

Production: ________________ No. of hours/day: ______ No. days/month: ________________Non-Production: ____________ No. of days with discharge/month: _______________________

C. Project and Product InformationTotal Floor Area (m2) __________________ Total Lot Area (m2) __________________________

For Agro-Industrial EstablishmentsTotal No. of Heads (based on LLDA Clearance) _____________ Total No. of Heads (actual) ____________________

Product 1 Product 2 Product 3 Product 4Product Name* N/A

Annual Production CapacityPrevious year’s actual production

D. Water Sources, Consumption and Wastewater GenerationBox C: Wastewater Generation (m3/day)

Box A: Sources (m3/day) Box B: 3 Recycled/ Lost by Contained in Treated by EffluentConsumption (m /day) Re-used Evaporation Lagoon, Ponds, Service Discharge to the

Septic Tanks Provider Environment

MWSI, MWCI Process Wastewater

Washing (cleaning ofLocal Water District equipment/kitchen wastes

from restaurants)

Deepwell Domestic Wastewater

Surface Water (lake, Cooling (make-up water)river, creek, etc.)

Others (drinking water,Others (specify) gardening, product

component, etc.)Total Water Total Water Total Wastewater DischargeSupply Consumption

NOTE: Box A and Box B must be equal (total water consumption)

E. Water Pollution InformationLocation& Description Name of the Estimated BOD Estimated Ave. Rate of Mode of Schedule of Discharge

of the Outlet Receiving Body of conc. (mg/l) Discharge (m3/day) Discharge (Date and Time)water

TOTAL

(continuation at the back)

LLDA-CPD-Form 11 Issue Date: April 2015 Issue No.: 01

F. Wastewater Treatment System Information

Septic Tank/s ( X) Wastewater Treatment Facility ( ) Sewage Treatment Plant ( ) Others: ____________ None ( )

Capacity __10___(m3/day) Total Capital Investment in treatment system: PhP____________Is there a physical treatment? Yes ( ) No ( ) Date Installed: ___________________

Screening ( ) Equalization ( ) Grit Removal ( ) Oil-Water Separator ( )Sedimentation ( ) If others, specify _______________________

Is there a chemical treatment? Yes ( ) No ( ) Date Installed: ___________________Adsorption ( ) Disinfection/Chlorination ( ) Flocculation/Coagulation ( )pH Adjustment ( ) If others, specify _______________________

Is there a biological treatment? Yes ( ) No ( ) Date Installed: ________________Activated Sludge ( ) Single Batch Reactor ( ) Anaerobic Digester/s ( ) Trickling Filters ( )Oxidation/Stabilization Pond ( ) Lagoons () Rotating Biological Contactor/s ( )If others, specify _______________________

Is there a tertiary treatment system? Yes ( ) No ( ) Date Installed: ________________Reverse Osmosis ( ) Microfiltration ( ) Ultrafiltration ( ) Nutrient Removal ( )

If others, specify ___________________

G. Flow Meter InformationIs flow meter installed? Yes ( ) No ( ) Type (specify):________________________________

H. Sludge ManagementQuantity of sludge _______________(m3/day)

Method of water removal from sludgeDrying Bed/s ( ) Vacuum Filtration ( ) Pressure Filtration ( ) Centrifugation ( ) If others, specify _______________

Method of DisposalLandfill inside the factory ( ) Landfill outside the factory ( ) Ocean dumping ( ) If others, specify ___________

I. Hazardous Waste ManagementMethod of disposal (specify): _______________________________________________________________DENR ID Number as Hazwaste Generator: __________________ Date issued: ____________________

J. Vicinity Map

I hereby certify that the information above are true, complete and accurate to the best of my knowledge.

________________________________________ _____________________________________Name & Signature of the Pollution Control Officer Name & Signature of the Chief Executive Officer

Date: _______________________________ Date: ___________________________

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 ___________________

NOTARY PUBLICDoc. No. ________Page No. ________Book No. ________Series No. ________

All information contained in this application form will be held strictly confidential.

LLDA-CPD-Form 11 Issue Date: April 2015 Issue No.: 01