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Document
SELF-ASSESSMENT TOOL FOR SITE SUITABILITY WI-109 Form
Code: 1
Section: Environmental and Occupational Health Revision
Rev 0
Section No.:
Core Process: Issuance of Certificate of Site
Suitability for Government Lots January 1,
Effectivity:
Applied for Presidential 2021
Proclamation/Special Patent

Date:
Name of the Facility/Establishment:
Name of Proponent:
Location:
Lot no.: Total area (m2):

Kindly encircle YES if the statement agrees to the existing site, NO if not.

Note:
a. Please provide information with all honesty as this will be the basis for the
issuance of Certificate of Site Suitability.
b. Attach pictures taking the following considerations:
 Full view of the lot including the facility/establishment built on it. Make sure
to include nearby houses, establishments, facilities, etc. outside the lot.
 All corners of the lot must be taken and provided with captions and
direction (north, east, south and west). Include in the caption the facilities,
establishments, residences, etc. near the corners.
 Take all corners and amenities inside the facility/establishment and
provide description.
c. All pictures must be clear and colored. Limit number of pictures to four (4) in A4
paper size.
d. Provide latest site development plan.

I. SITE LOCATION
1. Is the area adequate to
accommodate all the YES NO Area: __________________ m2
necessary facilities?
2. Is the zone designated by
Zoning Classification:
existing laws and ordinances YES NO
__________________________
for that type of development?
3. Is it accessible at least by
YES NO
land transportation?
4. Is the area along existing
road or proposed road
expansion/widening? Distance from any road
YES NO
(the property lines should be alignment: _______________ m
at least three (3) meters from
any road alignment)
5. Is the area located at a distance from any of the following potential sources of
pollution, noise, offensive odor, dust and nuisances
 Heavy Industries (non-
ferrous metal industries,
iron and steel mills,
Approximate distance from the
smelting plants, YES NO
area: ___________________ m
petroleum, and other
petrochemical industries,
including oil and gas)
 Resource Extractive Approximate distance from the
YES NO
Industries (major mining area: ___________________ m

McArthur Highway, Parian, City of San Fernando, 2500, La Union

Trunkline Nos. (072) 242 5315 to 16 (072) 242 4773 (072) 607 6431 (072) 607 6413
Facsimile No. (072) 242 4774; (072) 242-5981
Email Address: dohro1.rd@gmail.com Website: http://ro1.doh.gov.ph
 and quarrying projects,
forestry projects like
logging, grazing and
extraction of mangrove
products, fishery projects
including dikes and
fishpond development
projects)
 Power Generation
Operations (thermal,
geothermal, hydroelectric, Approximate distance from the
YES NO
nuclear, and other non- area: ___________________ m
traditional sources of
power and energy)
 Sanitary Landfills and
Approximate distance from the
other garbage disposal YES NO
area: ___________________ m
sites
 Piggery farm Approximate distance from the
YES NO
area: ___________________ m
 Poultry farm Approximate distance from the
YES NO
area: ___________________ m
6. Is the area located within (necessary certification from PHIVOLCS must be
obtained)
 Earthquake fault line YES NO
 Landslide or critical slope YES NO
 Flood-prone areas YES NO
 Lahar paths YES NO
 Volcanic activity YES NO
7. Is the area located at least
25 meters distance from any
If NO, provide approximate
burial ground/ YES NO
distance: ________________ m
cemetery/memorial park and
other place of interment?
8. Is it located in endemic areas
characterized by the
presence of diseases such
YES NO If YES, specify: ____________
as but not limited to malaria,
schistosomiasis, dengue and
filariasis?
9. Other Criteria Specific for School Sites
a. Presence of traffic
YES NO
hazards
b. Is it enough to
accommodate building
expansion, recreational
YES NO
areas, school gardens
and other school
amenities?
c. Is it accessible to the
YES NO
community it serves?
d. Is it located away from If YES, specify any sources of
disturbances and places disturbance/s near the lot:
which give undesirable
YES NO
influences such as
cockpits, dancing halls,
bars or recreational

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 places of questionable
character, bowling alleys,
movie houses, markets,
garbage dumps, funeral
parlors, jails, cemeteries
and other sources of
nuisances, as follows:
 200 meters
(minimum) from
bars, cocktail
lounges, karaoke
and sing-along
joints, abattoirs,
markets, movie
YES NO
houses, billiard
and pool halls,
bowling alleys,
video machines,
amusement and
recreational places
and the like;
 1000 meters
(minimum) from
jails, night clubs,
cabarets, disco
houses, massage
clinics, and sauna
baths, motels,
booking outlets of
racetracks and
lotto, cockpits, and
other places of
vice
10. Other Criteria Specific for
Camps and Picnic Grounds:
a. Is the camp or picnic
ground has at least 300
meters radial distance
away from densely
YES NO
populated areas (e.g
commercial, residential,
institutional and industrial
area)?
II. ADEQUATE AND POTABLE WATER SUPPLY
a. Are the water sources Specify water source:
have minimum quantity of
YES NO
40 liters per capita per
day?
b. If groundwater source Indicate approximate distance:
(such as deep/shallow
well, drilled well, etc.) is it
located within a minimum YES NO
distance of 25 meters
away from any source of
contamination?

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 c. If groundwater source Indicate approximate distance:
(such as deep/shallow
well, drilled well, etc.) is it
located within a minimum
YES NO
distance of 50 meters
away from
cemetery/memorial
park/private burial?
d. Are the water sources Indicate date of last issuance of
have certificate of Certificate of Potability of water
potability? YES NO source:

III. APPROPRIATE SEWAGE COLLECTION AND DISPOSAL (Based on the IRR

of Chapter XVII )
a. Is the
facility/establishment
YES NO
connected to a sewerage
system?
b. Is the
facility/establishment has YES NO
septic tank?
 Is the septic tank Indicate date of last desludging
desludged every 3 activity:
– 5 years?
YES NO
If not 3 – 5 years, how often?

IV. APPROPRIATE REFUSE OR SOLID WASTE DISPOSAL (Based on the IRR of

Chapter XVII – Refuse Disposal)
a. Is there a separate Specify the type of wastes
container for each type of generated in the
wastes (Biodegradable, facility/establishment:
Non-Biodegradable,
Recyclable, or “Infectious YES NO
Waste,” or “Chemical
Wastes,” or “Pathological
Wastes,” or “Radioactive
Wastes,” or “Sharps”)?
b. Are the containers
properly marked and YES NO
color – coded?
c. Is the solid waste Specify how often is the
container sufficient in collection of solid wastes in your
number and/or size to facility and the collection period
store the total volume of of the barangay where the lot is
YES NO
refuse produced within situated:
the collection period?

d. Other means of solid Specify:

waste disposal

V. POWER SUPPLY

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 a. Is there an available Specify power supply source:
power supply or YES NO
electricity?
VI. ACCESSIBILITY TO HEALTH FACILITY
a. Is the Specify distance to the nearest
facility/establishment health facility:
accessible to health
facility (either a Barangay YES NO
Health Station/ Rural
Health Unit/ City Health
Office/ Hospital?
VII. SANITARY PERMIT
a. Is the facility/ Specify date of issuance:
establishment secured
with Sanitary Permit to
YES NO
operate from the Local
Health Office of the
municipality/city?
VIII. HEALTH CERTIFICATE
a. Are the staffs assigned in Indicate the number of
food handling within the employees assigned on food
facility/establishment (e.g handling and the date of
those working in the issuance of HC of each:
canteen, and the like) has YES NO
secured an updated
health certificate from the
Local Health Office of the
municipality/city?
References: Memorandum No. 072 s. 2003 Environmental and Public Health Criteria
for Suitability of Sites Proposed for Presidential Proclamation

Presidential Decree 856, otherwise known as the Code on Sanitation of

the Philippines

I hereby understand that if I do not provide information with honesty it may jeopardize
environmental health and health of the public.

I declare that I have accomplished this Self – Assessment Tool for Site Suitability true, correct and complete
statement, pursuant to the provisions of PD 856, otherwise known as the Code on Sanitation of the Philippines. I
authorize the Regional Sanitary Engineer of the Department of Health Center for Health Development – I to
verify/validate the contents stated herein.

I agree that any misrepresentation made in this document and its attachments shall cause the filing of
administrative/criminal case/s against me.

BEFORE ME, a Notary Public for and in the City/Municipality of __________________, Province of
___________, personally came and appeared this ________ day of _________, 20__.

WITNESS MY HAND SEAL, the day, year and place written above.

_________________________________ _______________________________
Authorized Agent/ Representative Notary Public
(Signature over printed Name)

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