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Republic of the Philippines

Department of Environmental and Natural Resources App No
Environmental Management Bureau 35214
Region IV-B

APPLICATION FOR DISCHARGE PERMIT

BOX A: General Information

Type: Renewal
Name of Owner: MIRASOL DE JESUS
Office Address: 95 NATIONAL ROAD, Payompon, Mamburao (Capital), Occidental Mindoro

Name of Permittee: LA GENSOL PLAZA HOTEL INC TIN: 008468571000

PSIC Code: 55 Year Est.: 1997
Plant Address No & Street Name: 95 NATIONAL ROAD Barangay: Payompon
City or Municipality: MAMBURAO (Capital) Region: Region IV-B
Type of Industry: Hotels, motels, resorts, dormitories and other accommodation services
Name of PCO: CHRISTIAN DE JESUS Accreditation Date: Sept. 1, 2015
Tel. No. & Cel. No: 711-1072/09778393446 Fax No: 700-10-72

Legal Classification Private Corp

Ownership forms Private 100.0 % Foreign None % Government None %

BOX B: Employment and Operation Information

Total employment (number of workers) in the factory: Production: 9 Non Production: 0

Production Time: No of hours/day: 24 No of days/mo: 30

No of months/year: 12 No of days with discharge/mo: 0

BOX C: Sources of Water Supply and Wasterwater Generation

Monthly Daily Estimated

Sources of Water Supply ave vol. ave vol. Generating Process Flow
(m3) (m3) (m3/day)

MWSS (please attach water bills) 0.0 0.0 Process Wastewater 0.0

Local Water District (please attach water Washing/Cleaning of Process

0.0 0.0 0.0
bills) Eqpt.

Deep Well 300.0 0.0 Cooling 10.0

Surface water (lake, river, creek, etc.) 0.0 0.0 Domestic 0.0

Others 0.0 0.0 Recycled/Reuse 5.0

Others (drinking water, gardening,

evaporation, leaks, product 0.0
components, etc.)

Total Volume of Discharge

Total Water Consumption 300.0 0.0 0.0
Wastewater

BOX D: Dwelling Units Information (hotels, condominium, restaurants, malls, etc.)

Total Floor Area (m2): None No of Bedrooms: 31 No of Guests/year: None

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Total Area for Dining Units: None No of Restaurants/Dining Units: 1

BOX E: Product Information

Annual Annual
Product Name Production Production in the Type of Process
Capacity previous year

BOX F: Water Pollution Information

Ave. Rate of
Outlet Location and Description of the Name of the Receiving Ave. BOD, Ave. BOD
Discharge,
Number Outlet Body of Water mg/L Load, kg/day
m3/day

1 N/A - N/A None 0.0 0.0 0.0

Total 0.0 0.0 0.0

BOX G: Flow Meter Information

Flow meter is installed at: Effluent

Type of flow meter and method used at (effluent side): Direct Reading

BOX H: Information on the Wastewater Treatment System

Wastewater treatment system existing?: Yes ✔ No If YES, what is the capacity: N/A m3/day

Value of capital investent in the wastewater treatment plant: Php None

Is there a primary treatment system?: Yes ✔ No Date primary system installed:

If Yes, what is the composition of the physical treatment system:

Screening Equalization Grit Removal

Oil-Water separation (Floatation) Sedimentation (Primary Setting) If others, please specify:

Is there a chemical treatment?: Yes ✔ No Date primary system installed:

If Yes, what is the composition of the chemical treatment system:

Absorption Disinfection Flocculation/coagulation

pH Adjustment If others, specify: N/A

Is there a secondary treatment

Yes ✔ No Date primary system installed:
system?:

Activated Sludge Single Batch Reaction Anaerobic Digestion Oxidation/Stabilization (Pond)

Tricking Filtration Rotating Biological Contract If others, specify: N/A

Note: **Please use generic name. Not brand names, in metric tons of products except for the following subsectors:
hog raising (heads), carbonated drinks and beers (m3), slaughtering/preserving meat (ton LWK, electroplating (m2)).
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NOTARIZED CERTIFICATION

We hereby certify that the above information and attached documents are true and correct to the best of my
knowledge. Done this _________________________ day of ________________________,
__________________.

Name and Signature of the Pollution Control Chief Executive Officer

Officer (Name, Signature and Position)

SUBSCRIBED AND SWORN to before me a Notary Public. This __________ day of ______________________,
affliant exhibiting to me his/her _________________________________________________________________,
issued at ___________________________________________________________________________________
on ______________________________________________________________.

(Notary Public)