AFFIDAVIT

REPUBLIC OF THE PHILIPPINES)

CITY OF ______________) S.S

I, (Name) of legal age, married, residing at (_______), after being sworn in accordance with
law, depose and say that:

1. I am an applicant of Hazardous Waste Generator Registration pursuant to RA6969 and its

IRR DAO 1992-29 and Revised Procedures and Standards DAO 2013-22;

2. I am aware and understand all the duties, responsibilities and accountability to be

imposed upon me and my company (Company Name) by such application and as such
will be liable for all the damages incurred and for any untoward incident during its actual
operation;

3. I attest to the truth, accuracy and genuineness of all the information, documents and
records contained and attached to this application and that I and my company (Company
Name) shall be liable for any misrepresentation, fraudulent declaration and all its
consequences;

4. That the hazardous wastes generated are solely/exclusively transported and treated by
DENR accredited transporter and treater; and

5. I am executing this affidavit as a proof in good faith in complying with the requirements
for securing the abovementioned certificate.

IN WITNESS WHEREOF, I have hereunto set my hand this _______________day of

_________________ 2020 in ____________________________.

______________________________
Signature over printed name of affiant