SMR FORM.doc

8/12/2019 SMR FORM.doc

1/16

Department of Environment and Natural Resources

Environmental Management Bureau

G E N E R A L I N F O R M A T I O N ! E E T

Name of theEstablishment/Facility

Establishment/Facility

Address(NOTthe company of head

office)

Street # & Street Name: ___

Baranay: !ity/"nicipality: ___

$ro%ince:

Name of

'ner/!ompany

Address(if address is not the same as

pre%ios address)

Street # & Street Name: ___

Baranay: !ity/"nicipality: ___

$ro%ince:

$hone Nmber Fa Nmber

email address

*ype of Bsiness/

+ndstry !lassification

$hilippine Standard +ndstry !lassification !ode No, ___

$hilippine Standard +ndstry -escriptor: ___

___

.esponsible fficer/s:

!E/$resident, ___

*el #: Fa #: ___

email address: ___

$lant "anaer: ___

*el #: Fa #: ___

email address: ___

$olltion !ontrol

fficer

Name, ___

*el #: Fa #: ___

email address: ___

eal !lassification

sinle proprietorship partnership

pri%ate domestic corporation o%ernment corporation

"ltinational ___

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

Name/Sinatre of !E/$resident Name/Sinatre of $!

Reference No"

(to be filled p by -EN. only)


2/16

Name of Plant:

Department of Environment and Natural Resources

Environmental Management Bureau

# $ A R T E R L % E L F & M O N I T O R I N G R E ' O R T

MOD$LE (" GENERAL INFORMATION

Name of the $lant

$lease pro%ide the necessary re%ised0 corrected or pdated information not contained in yor General

Information Sheet

(se additional sheet/s if necessary)

DENR 'ermits)Licenses)*learancesEn%ironmental

a's$ermits -ate of +sse Epiry -ate

$,-, 123A/! No,

$ No,

$- 4526E!! 4

E!! 7

E!! 8

.A 6161

-EN.

.eistry +-

!! .eistry

+mporter

!learance No

$ermit to

*ransport

.A 2931A/! No,

$ No,

Module 1: General Information page____ of ____

Reference No"


3/16

Name of Plant:

Operation

peratin hors/day peratin days/'ee # of shift/day

A%erae

"aimm

Operation)'roduction)*apacit+"A%erae -aily $rodction

tpt*otal tpt this ;arter

*otal


4/16

Name of Plant:

MOD$LE ," RA -.-.

A/ **O Report 0please accomplis1 t1is section for eac1 c1emical)su2stance3

!ommon Name/+?$A!/!AS +nde Name, ___

!AS No,: ___

*rade Name: ___

For importers only:

;antity

.e@ested

+mport

!learance

No,

-ate of

Arri%al

;antity

.ecei%ed$ort of Entry

!ontry of

riin

!ontry of

"anfactre

*otal ;antity .e@ested

(annal)

*otal ;antity .ecei%ed

(annal)

attach copy/s of Bill of adin

For distribtors (importers/nonimporters)

Name of !lient icense No, ;antity -ate of -istribtion

*otal ;antity -istribted

For nonimporter sers:

Name of -istribtor ;antity -ate of $rchase

*otal ;antity $rchased from -istribtor

For prodcers

Module 2B: RA 6969 (Hazardous astes Generator! page____ of ____

Reference No"


5/16

Name of Plant:

A%erae -aily $rodction


;antity of Stoc

+n%entory (Start of

;arter)

;antity of Stoc

+n%entory (End of

;arter)Name of Byer ;antity -ate of $rchase

*otal ;antity Sold

$sed in 'roduction (please fill p only if chemical/sbstance is not main prodct)A%erae -aily $rodction


A%erae ;antity ?sed

per month

*otal ;antity ?sed this

;arter

-escribe any chanes in $rodction/$rocess/perations:

toc4 Inventor+)5aste *1emical Generated"A%erae ;antity of


6/16

Name of Plant:

!5 Generation"

>< No, >< !lass >< Natre>< from

$re%ios .eport>< enerated

;antity ?nit ;antity ?nit

5aste torage7 Treatment and Disposal"($lease fillp one table per >< -etails

>< No0: ___

;ty of >< *reated: ?nit: ___

*S- ocation: ___

StoraeName: ___

"ethod: ___

*ransporter+-: Name: ___

-ate: ___

*reater+-: Name: ___

"ethod: -ate: ___

-isposal+-: Name: ___

-ate: -ate: ___

>< -etails

>< No0: ___

;ty of >< *reated: ?nit: ___

*S- ocation: ___

Storae

Name: ___

"ethod: ___

*ransporter+-: Name: ___

-ate: ___

*reater+-: Name: ___

"ethod: -ate: ___

-isposal+-: Name: ___

-ate: -ate: ___

On&ite elf Inspection of torage Area"


Reference No"


7/16

Name of Plant:

-ate !ondcted $remises/Area +nspected Findins & bser%ations!orrecti%e Action *aen

(if any)


Reference No"


8/16

Name of Plant:

*/ !a6ardous 5astes Treater)Rec+cler

!5 tored and)or $ntreated as of End of #uarter"

>< Nmber


9/16

Name of Plant:

MOD$LE 8" '/D/ .9: 05ater 'ollution3

5ater 'ollution Data-omestic 'aste'ater(cbic meters/day)

$rocess 'aste'ater

(cbic meters/day)

!oolin 'ater

(cbic meters/day)

thers: ___________

(cbic meters/day)


10/16

Name of Plant:

Detailed Report of 5aste;ater *1aracteristics for *onventional 'ollutants

tlet No,

-A*EEfflent

Flo' .ate

(m8/day)

B-

(m/)

*SS

(m/)!olor p>

il &rease

(m/)

*emp rise

(!)

________(name)

(nit)

'lease fill&up)accomplis1 separate form)s for ot1er outlet)s/

Module ': P) 9*+ (ater Pollution! page____ of ____

Reference No"


11/16

Name of Plant:

Detailed Report of 5aste;ater *1aracteristics for Ot1er 'ollutants

tlet No,

-A*E

Efflent

Flo' .ate(m8/day)

________(name)

(nit)

________(name)

(nit)

________(name)

(nit)

________(name)

(nit)

________(name)

(nit)

________(name)

(nit)

________(name)

(nit)

'lease fill&up)accomplis1 separate form)s for ot1er outlet)s/

'lease use additional s1eet)s if necessar+/

Module ': P) 9*+ (ater Pollution! page____ of ____

Reference No"


12/16

Name of Plant:

MOD$LE :" R/A/ 9)Administrati%e and

%erhead !osts

!ost of operatin in

hose laboratory0 if any

+mpro%ement or

modification0 if any,

(-escription)

!ost of impro%ement of

modification

Module +: RA *,+9 (Air Pollution! page____ of ____

Reference No"


13/16

Name of Plant:

Detailed Report of Air Emission *1aracteristics-escription/ocation

of $!F

-A*EFlo' .ate

(Ncm/day)

!

(m/Ncm)

N(m/Ncm)

$articlates

(m/Ncm)

________(name)

(m/Ncm)

________(name)

(m/Ncm)

________(name)

(m/Ncm)

________(name)

(m/Ncm)

'lease fill&up)accomplis1 separate form)s for ot1er '*F)s/


Module +: RA *,+9 (Air Pollution! page____ of ____

Reference No"


14/16

Name of Plant:

MOD$LE =" '/D/ (=9-

Am2ient Air #ualit+ Monitoring 0if re>uired as part of E** conditions3-escription/ocation

of "onitorin

Station

-A*ENoisee%el

(dB)

!(m/Ncm

)

N(m/Ncm

)

$articlates

(m/Ncm)

________(name)

(m/Ncm

)

________(name)

(m/Ncm

)

________(name)

(m/Ncm

)

________(name)

(m/Ncm)

($lease accomplish one table per monitorin station,)

Am2ient 5ater #ualit+ Monitoring 0if re>uired as part of E** conditions3-escription/ocation

of Samplin Station

-A*E

________(name)

(nit)

________(name)

(nit)

________(name)

(nit)

________(name)

(nit)

________(name)

(nit)

________(name)

(nit)

________(name)

(nit)

________(name)

(nit)

($lease accomplish one table per samplin station,)

Module -: P) 1-*6 (.I/ /&stem! page____ of ____

Reference No"


15/16

Name of Plant:

Ot1er E** *onditions

E!! !ondition/sStats of !ompliance

Actions *aenDes No

4,

7,

8,

3,

5,

6,


Environmental Management 'lan)'rogram

Enhancement/"itiation "easresStats of

+mplementation Actions *aenDes No

4,

7,

8,

3,

5,

6,


olid 5aste *1aracteri6ation)Information"A%erae ;antity of

Solid


16/16

Name of Plant:

MOD$LE -" OT!ER

Accidents ? Emergenc+ Records

-ate Area/ocationFindins and

bser%ation Actions *aen .emars

'ersonnel)taff Training

-ate !ondcted !orse/*rainin -escription# of $ersonnel

*rained

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

-one this _________________________0 in ________________________,

Name/Sinatre of $!

Name/Sinatre of !E

S?BS!.+BE- AN- S

Documents

SMR FORM.doc