REPUBLIC OF THE PHILIPPINES )

PROVINCE OF ORIENTAL MINDORO ) S.S.

MUNICIPALITY OF BONGABONG )

AFFIDAVIT

I, , of legal age, married Filipino and residing at, after having been duly sworn to in
accordance with law, depose and say that:

1. I am the registered Pollution Control Officer (PCO)

2. Pursuant to RA 6969 : Toxic Substances and Hazardous Waste Control Act of
1990, all establishment that are being regulated under EMB-DENR must be a
registered hazardous waste generator generator to achieve measurable results
related to compliance with environment regulations and protection of environment
and public health;

3. Part of the requirements prescribed is to submit an accomplished Hazardous

waste Generator registration Form (HWM Form A ver. 2018)

4. I hereby certify under oath that all the information documents and records
contained and attached in the registration form are all true, correct and genuine.

5. I am executing this Affidavit in good faith to attest to the truth of the foregoing
statements and for the purpose of complying with the requirements prescribed by
DENR.

IN WINESS WHEREOF, I have hereunto signed this ______ day of March 2020 at
_____________________________________________, Oriental Mindoro.

Affiant

SUBSCRIBED AND SWORN to before me this ____ day of March 2020 at

___________________________________________,Oriental Mindoro, Philippines, affiant exhibiting to
me her valid proof of identification.

Doc No. ________________

Page No. _______________
Book No. _______________
Series of _______________