Department of Environment and Natural Resources

Environmental Management Bureau

Reference No.:

( to be filled up be DENR only)

GENERAL INFORMATION SHEET

Name of the
Establishment/Facility BLUE OVAL AUTOMOTIVE CORP. (FORD ILOCOS NORTE)
Establishment/Facility Street# & Street Name: _National Hi-way__________________________
Address Barangay: #16, San Marcos_________________ City/Municipality: San Nicolas_________
(NOT The company of Province: Ilocos Norte____________________
head office)
Name of
Owner/Company BLUE OVAL AUTOMOTIVE CORP (FORD ILOCOS NORTE)
Address Street# & Street Name: _National
Hi-way___________________
(if address is not the Barangay: _16, San Marcos_________________ City/Municipality: _San Nicolas________
same as previous Province: _Ilocos Norte____________________
address)
Phone Number (077) 617-1063 Fax Number (077) 617-0167

e-mail address
Type of Business/ Philippine Standard Industry Classification Code No. ____________________________________________________
Industry Philippine Standard Industry Descriptor: _______________________________________________________________
Classification ____________________________________________________________________________________________________
CEO/President: _____________________________________________________________________________________
Tel #:_____________________________________________ Fax
Responsible #:________________________________________
Officer/s: e-mail address: ____________________________________________________________________________________
Business Manager: _JOHN
BENCER D. DUYA_____________________________________
Tel #:_09188542300____________________ Fax
#:________________________________________
e-mail address: _jdduya@lausgroup.com.ph_______________________________
Pollution Control Name: _Jerry A. Aguilar__
Officer Tel #: 0922.290.3371______________________ Fax
#:________________________________________
e-mail address: _jaaguilar@lausgroup.com.ph_______________________________________
Legal Classification  Single proprietorship  Partnership
 Private domestic corporation X  Government corporation
 Multi-national  ____________________________________
We hereby certify that the above information are true and correct.

JOHN BENCER
EDUARDO D. DUYA
U. MAHINAY JERRY A. AGUILAR (PCO - For Accreditation)
________________________________________ ________________________________________
Name/Signature of Business Manager Name/Signature of PCO
Name of Plant : BLUE OVAL AUTOMOTIVE CORPORATION (FORD Ilocos Norte) Reference No.:
____________________________________________________________________________
Department of Environment and Natural Resources
Environmental Management Bureau
4th QUARTERLY SELF-MONITORING REPORT for the period Oct. - Dec., 2019
MODULE 1: GENERAL INFORMATION
Name of Plant
Please provide the necessary revised, corrected or updated information not contained in your
General Information Sheet
Blue Oval Automotive Corp. (Ford Ilocos Norte) is an exclusive dealer of FORD motor vehicles, retailing, and
service repair and maintenance.

( use additional sheet/s if necessary)

DENR Permits/Licenses/Clearances
Environmental Laws Permits Date of Issue Expiry Date
R.A. 9275 A/C No. n/a
PO. No. WWDP-15H-01IN16-063 Sept. 11, Aug. 23,
2015 2020
ECC 1 CNC-OL-RO1-2016-06-07125
PD 1586 ECC 2 n/a
ECC 3 n/a
DENR GR-R1-28-00051 Amended on
Registry ID June 28,
2018
CCO Registry n/a
RA 6969 Importer n/a
Clearance No.
Permit to n/a
Transport
RA 8749 A/C No. POA - 16K -O1IN16-071 Nov. 16, 2018 Nov. 10, 2021
PO No. n/a

Module 1: General Information page __1__ of __15_

Name of Plant : BLUE OVAL AUTOMOTIVE CORPORATION (FORD Ilocos Reference No.:
Norte)______________________________________________________________________
_____

Operation
Operating hours/day Operating days/week # of shift/day
Average 8 hrs/day 6days / week 1 Shift/ day
Maximum 10 hrs/day

Operation/Production/ Capacity:
Average Daily Production 5.9 URs (Units Total Output this Quarter
Output received for )
426 URs
Preventive
maintenance)
Total Water Consumption Total Electric Consumption
125.54 m3 12, 680 KWH
this Quarter ( cubic meters) this Quarter (KwH)
Please use additional sheet/s if necessary
Module 1: General Information page __2___ of ___15_
Name of Plant : BLUE OVAL AUTOMOTIVE CORPORATION (FORD Ilocos Norte) Reference No.:
____________________________________________________________________________

MODULE 2: RA 6969

A. CCO Report (please accomplish this section for each chemical/substance)

Common Name/ UPAC/CAS Index Name: _______________________________________________________________

_______________________________________________________________ CAS No.:______________________________
Trade Name: __________________________________________________________________________________________

For importers only:

Quantity Import Date of Quantity Port of Country of Country of
Requested Clearance Arrival Received Entry Origin Manufacture
No.

N/A
Total Quantity Total Quantity
Requested ( annual) Received ( annual)
*attach copy/s of Bill of Lading

For Distributors (Importers/Non-importers)

Name of Client License No. Quantity Date of Distribution

N/A

Total Quantity Distributed

For Non-importer users:

Name of Distributor Quantity Date of Purchase

N/A

Total Quantity Purchased form Distributor

Module 2A: RA 6969 ( CCO Report ) page __3__ of ___15

Name of Plant : BLUE OVAL AUTOMOTIVE CORPORATION (FORD Ilocos Norte) Reference No.:
____________________________________________________________________________

For producers
Average Daily Total Output this
Production Output Quarter
Quantity of Stock Quantity of Stock
Inventory( Start of Inventory( End of
Quarter) Quarter)
Name of Buyer Quantity Date of Purchase

N/A

Total Quantity Sold

Used in Production (please fill up only if chemicals/substances is not main product)
Average Daily Total Output this
Production Output Quarter
Average Quantity Used Total Quantity Used
per month this Quarter

Describe any changes in Production/Process/Operations:

N/A

Stock Inventory/ Waste Chemical Generated:

Average Quantity of Total Quantity of Waste
Waste Chemical Chemical Generated
Generated per month this quarter
Quantity of Stock N/A Quantity of Stock N/A
Inventory ( Start of Inventory ( End of
Quarter) Quarter)

Other Information:
Manner of handling
hazardous wastes
Changes in Safety
Management System
Chemical Substitute
Plan
 Storage on-site X  Treatment on-site
 Storage off-site  Treatment off-site
 Yes( Please attach copy of revised plan)
 No X
 Yes( Please attach copy if not submitted/included in previous report/s or had been revised)
 No

Module 2A: RA 6969 ( CCO Report ) page __4_ of _15__

Name of Plant : BLUE OVAL AUTOMOTIVE CORPORATION (FORD Ilocos Norte) Reference No.:
____________________________________________________________________________

B. Hazardous Wastes Generator

HW Generation:
HW Remaining HW from HW Generated
HW No. HW Class HW Nature Cataloging Previous Report
Quantity Unit Quantity Unit
I 101 -OIL USED OIL - Liquid 5.35 - TON 2.13 Ton
I104 -Oil Used Oil & Fuel - Solid -0.114 Ton 0.0106 Ton
Contaminated Filters
Substance
D406 Lead Vehicle Batteries - Solid 0.030 Ton 0 Ton
Compounds from Warranty
D407 Mercury & Replaced Busted - Solid 0.000020 Ton 0 Ton
Mercury Bulbs
compounds
J201 Containers Brake cleaners, - Solid 0.0120 Ton 0.00127 Ton
previously paint cans
containing toxic
substances
Waste Storage, Treatment and Disposal: (Please fill-up one table per HW)
HW No. :__I 101 USED OIL_____________________________________________________________________
HW Details QTY. of HW Treated: ______________________________________________ Unit: __TON__________
TSD Location :_____________________________________________________________________________________
Storage Name:____________________________________________________________________________________________
Method: __________________________________________________________________________________________
ID:_______ Name: ____________________
Transporter Date:_________________________________
Treater ID:_ ___ Name: ______
Method: ___________________Date:____
Disposal ID:_______________________________ Name: ___________________________________________________________
Date: ______________________________________________Date:____________________________________________

HW No.: ___________________________________________________________________________________________
HW Details Qty of HW Treated: _____________________________________________________ Unit: _______________________
TSD Location :_______________________________________________________________________________________
Storage Name:____________________________________________________________________________________________
Method: __________________________________________________________________________________________
ID:_______________________________ Name: ___________________________________________________________
Transporter Date:_______________________________________________________________________________________________
Treater ID:_______________________________ Name: ___________________________________________________________
Method: ____________________________________________________________Date:___________________________
Disposal ID:_______________________________ Name: ___________________________________________________________
Date: ______________________________________________Date:____________________________________________
Module 2B: RA 6969 (Hazardous Wastes Generator) page __5___ of __15_

Reference No.:
Name of Plant : BLUE OVAL AUTOMOTIVE CORPORATION (FORD Ilocos Norte)

____________________________________________________________________________

On-Site Self Inspection of Storage Area:

Date Conducted Premises/Area Findings& Corrective Actions
Inspected Observations Taken ( if any)
Service Area All are organized and
Twice a Month well segregated
Module 2B: RA 6969 (Hazardous Wastes Generator) page __6_ of __15_
Name of Plant : BLUE OVAL AUTOMOTIVE CORPORATION (FORD Ilocos Norte) Reference No.:
____________________________________________________________________________

C. Hazardous Wastes Treater/ Recycler

HW Stored and/or Untreated as of End of Quarter:

Transport Type of Storage
HW Number Wastes Date of Permit/Date Valid Until Quantity Container/# of Time Table for
Generator Transport of Issue Containers Treatment

HW Treated and/or Recycled as of End of Quarter:

Transport Type of Type &
Type of HW Number Wastes Date of Permit/Date Quantity Treatment or Quantity of
Wastes Generator Transport of Issue Recycling Recycled or
Process Treated
Product
Residual Wastes Generated from the Treatment and/or Recycling Operation:
Process by Type of Storage
which the Quantity Container/# of Disposal Option Time Table
Type of Wastes HW Number
Wastes is Containers For Disposal
Generated

N/A

Module 2C: RA 6969 (Hazardous Wastes Treater/ Recycler) page __7_ of __15___
Name of Plant : BLUE OVAL AUTOMOTIVE CORPORATION (FORD Ilocos Norte) Reference No.:
____________________________________________________________________________

MODULE 3: R.A. 9275 (Water Pollution)

Water Pollution Data

Domestic wastewater Process wastewater

(cubic meters/day) (cubic meters/day)
Cooling water (cubic Others: __________
meters/day) Wash (cubic meters/day)
water, equipment Wash water, floor 1.793 m3
(m3/day) (cubic meters/day)

Record of Cost of Treatment (Separate entries for separate facilities)

Month 1 Month 2 Month 3
Person employed, (# of
employees)
Person employed, (cost)
Cost of Chemicals used by
WTP
Utility Costs of WTP
(electricity & water) N/A
Administrative and
Overhead Costs
Costs of operation in house
laboratory

New/Additional
Investment in WTP
(Description)

Costs of New/Add
Investment

WTP Discharge Location

Outlet
Number Location of the Outlet Name of Receiving Water Body

1 National Hi-way, Brgy. 16, San Municipal Drainage

Marcos, San Nicolas, Ilocos
Norte
2
3
4
5

Module 3: R.A. 9275 (Water Pollution) page __8_ of __15_

Name of Plant : BLUE OVAL AUTOMOTIVE CORPORATION (FORD Ilocos Norte) Reference No.:
____________________________________________________________________________

Detailed Report of Wastewater Characteristics for Conventional Pollutants

Outlet No.

DATE Effluent BOD TSS Oil & Temp (name)

Flow Rate (mg/L) (mg/L) Color pH Grease rise (o C)
(m3/da (mg/L)
(unit)

Jan. 1.039m3 116.0

12, mg/L
2016
Mar. 1.2285m3 19.0
20, mg/L
2017
Jan. 1.5829m3 20.0 60.0mg/L
11, mg/L
2018
Jan. 41
17, mg/L
2019
For Schedule at DOST Regional Office
Please fill-up/accomplish separate form/s for other outlet/s.

Module 3: R.A. 9275 (Water Pollution) page __9__ of __15_

Name of Plant : BLUE OVAL AUTOMOTIVE CORPORATION (FORD Ilocos Norte) Reference No.:
____________________________________________________________________________

Detailed Report of wastewater Characteristics for Other Pollutants

Outlet No.
Effluent
DATE Flow Rate (name) (name) (name) (name) (name) (name) (name)
(m3/da
(unit) (unit) (unit) (unit) (unit) (unit) (unit)

N/A
Please fill-up/accomplish separate form/s for other outlet/s.
Please use additional sheet/s if necessary.

Module 3: R.A. 9275 (Water Pollution) page __10_ of __15_

Name of Plant : BLUE OVAL AUTOMOTIVE CORPORATION (FORD Ilocos Norte) Reference No.:
____________________________________________________________________________
MODULE 4: R.A. 8749 (Air Pollution)

Summary of APSE/APCF

Process Equipment Location # of hrs of operations

1.
2.
3.
4.
Fuel Burning Location Fuel Used Quantity # of hrs of
Equipment Consumed operation
1. 134 Hp Engine Room - Blue 200 ltrs. 18 hrs.
Dongfeng Oval Automotive Diesel October - Dec.
Cummins Corp.- Ford Ilocos
6BT5.9-G1 Norte
Disele Engine
2.
3.
4.
5.
6.
Pollution Control Facility Location # of hrs of operation
1.
2.
3.
4.

Cost of Treatment
 Month 1 Month 2 Month 3
Cost of Person
employed, (salary)
Total Consumption of
Water (cubic meters)
Total Cost of
chemicals used (e.g.,
activated carbon, N/A
KMnO4)
Total Consumption of
Electricity (KwH)
Administrative and
Overhead Costs
Cost of operation in-
house laboratory, if
any
Improvement or
modification, if any.
(Description)

Cost of improvement
of modification

Module 4: R.A. 8749 (Air Pollution) page __11_ of _15__

Name of Plant :: BLUE OVAL AUTOMOTIVE CORPORATION (FORD Ilocos Norte) Reference No.:
____________________________________________________________________________

Detailed Report of Air Emission Characteristics

Description/Location
of PCF

DATE Flow Rate CO NOx Paticulates (name) (name) (name) (name)

(Ncm/day (mg/Ncm) (mg/Ncm) (mg/Ncm) (mg/Ncm) (mg/Ncm) (mg/Ncm) (mg/Ncm)
 Please fill-up/accomplish separate form/s for other PCF/s.
Please use additional sheet/s if necessary.

Module 4: R.A. 8749 (Air Pollution) page __12_ of __15_

Name of Plant : : BLUE OVAL AUTOMOTIVE CORPORATION (FORD Ilocos Norte) Reference No.:
____________________________________________________________________________

MODULE 5: P.D. 1586

Ambient Air Quality Monitoring (if required as part of ECC conditions)

Description/Location
of Monitoring Station

DATE Noise Level CO NOx Particulates (name) (name) (name) (name)

(dB) (mg/Ncm) (mg/Ncm) (mg/Ncm) (mg/Ncm) (mg/Ncm) (mg/Ncm) (mg/Ncm)

(Please accomplish one table per monitoring station.)

Ambient Water Quality Monitoring (if required as part of ECC conditions)

Description
/Location
of Sampling (name) (name) (name) (name) (name) (name) (name) (name)
 Station
(unit) (unit) (unit) (unit) (unit) (unit) (unit) (unit)
DATE

N/A

(Please accomplish one table per sampling station.)

Module 5: P.D. 1586 (EIS Systen) page _13__ of __15_

Name of Plant :: BLUE OVAL AUTOMOTIVE CORPORATION (FORD Ilocos Norte) Reference No.:
____________________________________________________________________________

Other ECC Conditions

Status of Compliance
ECC Condition/s Yes No Actions Taken

1.
2.
3.
4.
5.
N/A
6.
7.
Please use additional sheet/s if necessary.

Environmental Management Plan/Program

Status of
Enhancement/Mitigation Measures Implementation Actions Taken
Yes No
1.
2.
3.
4.
5.
N/A
6.
7.
Please use additional sheet/s if necessary.

Solid Waste Characterization/Information:

Average Quantity of 0.1198 Tons. or 12 Total Quantity of Solid 0.3594Tons

Solid Wastes Generated Garbage bag per Wastes Generated this
per month Average Month ( Plastics, Quarter Total Quantity
Quantity of Solid Wastes papers, cans) of Solid Wastes
Collected per month Collected this Quarter
Entity in charge of
collecting solid wastes Municipal Garbage Collector every Wednesdays

Brief Description of Blue Oval automotive Corp. (Ford Ilocos Norte) segregate solid
Solid Waste waste and temporary stock in a Labeled Trash Cans and collected
Management Plan (e.g., by the Municipal Garbage Truck Every Wednesday (Schedule:
waste reduction, Morning is exclusive for biodegradable wastes and PM is for Non-
segregation, recycling) biodegradable)

Module 5: P.D. 1586 (EIS Systen) page __14_ of __15_

Name of Plant : BLUE OVAL AUTOMOTIVE CORPORATION (FORD Ilocos Norte) Reference No.:
____________________________________________________________________________

MODULE 6: OTHERS

Accidents & Emergency Records

Date Area/Location Findings and Actions Taken Remarks

Observation

N/A

Personnel/Staff Training
# of Personnel Trained
Date Conducted Course/Training Description

I hereby certify that the above information are true and correct.

Done this ___ 10th day of January 2020_, in _Brgy. 16, San Marcos, San Nicolas,
Ilocos Norte.
 John Bencer D. Duya Jerry A. Aguilar (PCO - For Accreditation)
Name/Signature of Business Manager Name/Signature of PCO

SUBSCRIBED AND SWORN before me, a Notary Public, this _______ day of ______________,
affiants exhibiting to me their Community Tax Receipts:

Name CTR No. Issued at Issued on

_____________________ ______________ _____________ ______________
_____________________ ______________ _____________ ______________

Module 6 Others page __15_ of __15_

Name of Plant : BLUE OVAL AUTOMOTIVE CORPORATION (FORD Ilocos Norte) Reference No.:
____________________________________________________________________________