Professional Documents
Culture Documents
Environmental Management Bureau: Office of The Regional Director
Environmental Management Bureau: Office of The Regional Director
Application No.
INSTRUCTION: Fill in all appropriate white spaces. Mark all appropriate boxes with an “X”.
NOTE: Failure to complete this form may be sufficient ground for disapproval of the permit application.
GENERAL INFORMATION:
Type of Industry:
Legal Classification
Product Name
Actual Production
Note: **Please use generic product name, not in brand names, in metric tons of product, carbonated drinks and beer (m3)
except for the following substances: hog raising(heads) slaughtering/preserving
Vicinity Map (The map should show relative location of the establishment with respect to existing structures, landmarks, rivers, lakes and
Other water bodies, etc..Use scale to fit into the frame below.
I hereby certify that the above information are true and correct to the best of my knowledge. Done this _________day of_________________
of 20______________.
_________________________________________________ _______________________________________________
Name and Signature of the Pollution Control Officer CEO / MANAGER
SUBSCRIBE AND SWORN to before a Notary Public. This __________ day of ____________________.Affiant exhibiting to me his/her
Community Tax Receipt NO._________________Issued at _______________________ on______________________.
NOTARY PUBLIC
REQUIREMENTS FOR APPLICATION FOR A WASTEWATER DISCHARGE
PERMIT
A registered chemical or sanitary engineer or Pollution Control Officer shall sign such engineer
report concurred by the Managing Head.
b) A copy of the quarterly self-monitoring report for the immediately preceding year.
c) A copy of the Certificate of Accreditation of the Pollution Control Officer duly issued by the
department, or appointment/designation as such by the Managing Head;
d) Official receipt for the payment of the applicable Fixed fee; and
e) Other documents that may be required related to land application