Republic of the Philippines ESG.1.F.

001
Revision No.: 12
Philippine Economic Zone Authority Effectivity Date: 17 June 2022
Application Form for Accreditation as Residual Waste Hauler

WASTE COLLECTOR INFORMATION

Company Name :

Facility Address :

Company Head / Owner:

Complete Mailing Address:

Contact Person : Designation:

Telephone No. : Fax No. :

Mobile No. : email Address:
Please provide the following documentary requirements:
o Business/ Mayor’s Permit o Solid Waste Management & Transport Training
Permit #: _____________________ Validity:_______________ Certificate
o Notarized Agreement to Dump o Location Map
o ECC of SLF / DOST Validation Report for ATF o Anti-Graft Certificate
o Geotagged photos showing compliance to MRF and vehicle requirements o Specimen Signature
WASTE TRANSPORT VEHICLES
Please specify the following information for each vehicle to be used: (Use other sheet and follow the same format if necessary)
Please provide the following documents
SERIES / COLOR VOLUME for each specified vehicle:
PLATE NO. MAKE CAPACITY
BODY TYPE (ACTUAL) Deed of Sale or
Photos OR CR Lease Contract
(if applicable)

1.    
2.    
3.    
4.    
5.    

WASTE DISPOSAL OR TREATMENT FACILITIES

Please check the appropriate facility and provide the necessary documents :
FACILITY DOCUMENTARY REQUIREMENTS

 SANITARY LANDFILL: o Environmental Compliance Certificate (ECC)

ECC # : _____________________________
________________________________

 MATERIALS RECOVERY FACILITY: o Environmental Compliance Certificate (ECC)/Certificate of Non-Coverage (CNC)

ECC/CNC # : _________________________
________________________________

o DOST-ITDI Validity/Verification Report

 ALTERNATIVE TECHNOLOGY FACILITY: Date Issued : ________________________

________________________________ o Environmental Compliance Certificate (ECC)/Certificate of Non-Coverage (CNC)

ECC/CNC # : _________________________

CERTIFICATION
I hereby certify that the above information is true and correct, and that we understand and agree with all the rules and regulations being implemented
by PEZA, and failure to comply with such may lead to forfeiture or non-acceptance of my application.
(Pinapatunayan ko na lahat ng impormasyong aking nailahad ay totoo at tama. Lubos kong naiintindihan at ako’y sumasang-ayon sa mga alituntunin na
pinaiiral ng PEZA. Nauunawaan ko din na hindi tatanggapin ang aking aplikasyon kapag kulang ang requirements na aking sinumite.)

_________________________________________________________ ___________________________
Signature Over Printed Name of the Owner/General Manager Date
Please do not write below this line (For PEZA use only)
Remarks:
 Complete ___________________________
 Incomplete ESG/EHSD Personnel

e-order of payment # Official Receipt No. Date of Payment Amount Paid

 ESG.1.F.036
Revision No.: 03
Effectivity Date: 17 June 2022
Republic of the Philippines
Philippine Economic Zone Authority

Company Name: ___________________________________________________

Facility Address: ___________________________________________________

SPECIMEN SIGNATURE OF PERSONNEL AUTHORIZED TO SIGN GATE PASS

NAME SIGNATURE
1.

2.

3.

4.

5.

6.

7.

8.

9.

10.

CERTIFIED TRUE AND CORRECT:

__________________________________
Signature over Printed Name of Owner
or General Manager
 ANTI-GRAFT CERTIFICATE

I, , of legal age, President/General Manager

of with postal address at

after having been duly sworn, depose and say:

That pursuant to the provisions of Section 3 and 14 of Republic Act 3019 (Anti-Graft Act), the
applicant enterprise, has not
given or promised to give, and will not give, any gift to any officer employee of the PEZA in connection wth the filing
and processing of this application, nor it will give such gift to any of said officers or employees after approval of its
application.

That based on the records of the applicant, no Board Member or Officer of the Philippine Economic Zone
Authority has an investment or other financial interest, direct or indirect, in the applicant.

That this certificate was made with the approval of applicant's Board of Directors.

Affiant

Subscribed and sworn to before me this day of , 20

in the City / Province of . Affiant exhibited to me his Residence Tax
Certificate No. A. issued at
on , 20 .

Notary Public
Until December 31, 20_____

Doc. No.
Page No.
Book No.
Series of 20