DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCES

ENVIRONMENTAL MANAGEMENT BUREAU REGION 8

DENR Compound, Brgy. 2, Tacloban City

APPLICATION FORM FOR DISCHARGE PERMIT

INSTRUCTION: Fill in all appropriate white spaces. Mark all appropriate boxes with an “x”.

NOTE: Failure to complete this form may be sufficient ground for disapproval of
the Permit application.

New TIN:

Renewal Expiry Date

Application No.

Capital Investment: Authorized: PhP_________________Paid Up: ___________________

General Information

Name of Establishment/Plant Est Code Year Yr. Established

Plant Address No. & Street Name Barangay

City or Municipality Province

Type of Industry

Name of PCO Accreditation Date

Tel. No. & Cel. No. Fax No.

Legal Classification Proprietor Private Corporation Multinational Others: Specify

Ownership Terms % Private % Foreign % Government %

Employment and Operation Information

Total Employment (number of workers) in the factor: Production Non Production

Production Time: Number of hours/day No. of days/mo. No. of mo./yr

Sources of Water Supply and Wastewater Generation

Sources of Water Supply Monthly Ave. Daily Ave. Generating Process Estimated Flow
Vol. (m3) Vol. (m3) (m3/day)
MWSS (pls. Attach water Process wastewater
bills)
Local Water District (pls. Washing/Cleaning of
attach water bills) Process Equipment
Deep Well Cooling
Surface Water (lake, river, Domestic
creek, etc.)
Others, please specify Recycled/Reuse
______________________ Others (drinking water,
gardening, evaporation,
leaks products
components, etc.)

FM-CPD-26 00 10-01-17
Total Water Consumption Total Volume of
Discharge Wastewater

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

Total Floor Area (m2) No. of Bedrooms No. of Guest/yr.

Total Area for Dwelling Unit No. of Restaurant/Dining Unit

Product Information
Product I Product 2 Product 3
Product Name
Design Production Capacity
Actual Production Capacity

Type of Process Batch [ ] Batch [ ] Batch [ ]

Continuous [ ] Continuous [ ] Continuous [ ]

Note: ** Please use generic name, not in brand names, in metric tons of products except for the following substance: hog raising (heads),
carbonated drinks and beers (m3), slaughtering/preserving meat (ton LWK, electroplating (m2).
Water Pollution Information
Name of the
Estimated
Receiving Body of Estimated Average Estimated Ave.
Description of Location of the Average rate of
water. For land BOD/Concentration TSS/BOD Load
Outlet outlet Discharge
disposal, specify TSS(mg/l) (kg./day)
(m3/day)
the area.
1
2
3
Total

Name of laboratory performing analyst: ___________________________________________________

Address of Laboratory:_________________________________________________________________
Date of Sampling: ____________________________Date of Analysis:______________________
Method of Sampling : _____________________________________________________________

I hereby certify that the above information is true and correct to the best of my knowledge. Done
this __________day of ___________ of 20____.

________________________________ ____________________________
Name & Signature of the Pollution Control Officer Chief Executive Officer
(Name, Signature and Position)

SUBSCRIBED AND SWORN to before a Notary Public. This ____ day of _____, Affiant exhibiting to me his/her
Community Tax Receipt No._________ Issued.

NOTARY PUBLIC

FM-CPD-26 00 10-01-17