LLDA Discharge Permit Application Form

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Information about LLDA Discharge Permit Application Form

Published on September 5, 2016

Author: DENR_PERMITS_PREPARER

Source: slideshare.net

1. LAGUNA LAKE DEVELOPMENT AUTHORITY National Ecology Center, East Avenue Diliman, Quezon City Tel. Nos.:332-2346, 376-4039, 376-4072, 376-4049, 376-4061 APPLICATION FOR DISCHARGE PERMIT NEW RENEWAL REVALIDATION Expiry Date of latest DP: ____________ A. APPLICANT INFORMATION Name of Establishment/Project:_________________ Tax Identification Number (TIN): ________________________ Year Established:____________________ Location of Establishment/Project: Number and Street: _______________________ City/Municipality: ________________________ Province:_____________________________ Tel. # :_______________________________ Fax#: ___________________________________ Business Activity: __________________________________________________________ Applicant’s Pollution Control Officer: Name: ____________________________________Cert.ofAccreditation No.:_______________________ Cel. #: ________________________________email add: __________________________________________ B. Employment and Operation Information Total Employment(number ofworkers) Operational Schedule/Time Production: ________________ No. of hours/day: ______ No. days/month: ________________ Non-Production: ____________ No. of days with discharge/month:_______________________ C. Project and Product Information Total Floor Area (m2) __________________ Total LotArea (m2) __________________________ For Agro-Industrial Establishments Total No. of Heads (based on LLDA Clearance) _____________ Total No.of Heads (actual) ____________________ Product 1 Product 2 Product 3 Product 4 Product Name* N/A Annual Production Capacity Previous year’s actual production D. Water Sources, Consumption and Wastewater Generation Box C: Wastew aterGeneration (m3/day) Box A: Sources (m3/day) Box B: 3 Recy cled/ Lost by Contained in Treated by Effluent Consumption (m/day) Re-used Evaporati on Lagoon, Ponds, Servi ce Discharge to the Septic Tanks Provi der Environm ent MWSI, MWCI Process Wastewater Washing (cleaning of Local Water District equipm ent/ki tc hen wastes f rom restaurants) Deepwell Domestic Wastewater Surface Water (lake, Cooling (make-up water) river, creek, etc.) Others (drinking water, Others (specify) gardening, product component, etc.) Total Water Total Water Total Wastewater Discharge Supply Consumption NOTE: Box A and Box B must be equal (total water consumption) E. Water Pollution Information Location& Description Name of the Estimated BOD Estimated Ave. Rate of Mode of Schedule of Discharge of the Outlet Receiving Body of conc. (mg/l) Discharge (m3/day) Discharge (Date and Time) w ater TOTAL (continuation at the back) LLDA-CPD-Form 11 Issue Date: April2015 Issue No.: 01

2. F. Wastewater TreatmentSystem Information Septic Tank/s ( X)Wastew ater Treatment Facility ( ) Sewage Treatment Plant ( ) Others: ____________ None ( ) Capacity __10___(m3/day) Total Capital Investment in treatment system: PhP____________ Is there a physicaltreatment? Yes ( ) No ( ) Date Installed: ___________________ Screening ( ) Equalization ( ) Grit Removal ( ) Oil-Water Separator ( ) Sedimentation ( ) If others, specify _______________________ Is there a chemical treatment? Yes ( ) No ( ) Date Installed: ___________________ Adsorption ( ) Disinfection/Chlorination ( ) Flocculation/Coagulation ( ) pH Adjustment ( ) If others, specify _______________________ Is there a biological treatment? Yes ( ) No ( ) Date Installed: ________________ Activated Sludge ( ) Single Batch Reactor ( ) Anaerobic Digester/s ( ) Trickling Filters ( ) Oxidation/Stabilization Pond ( ) Lagoons () Rotating Biological Contactor/s ( ) If others, specify _______________________ Is there a tertiary treatment system? Yes ( ) No ( ) Date Installed: ________________ Reverse Osmosis ( ) Microfiltration ( ) Ultrafiltration ( ) Nutrient Removal ( ) If others, specify ___________________ G. FlowM eter Information Is flow meter installed? Yes ( ) No ( ) Type (specify):________________________________ H. Sludge Management Quantity of sludge _______________(m3/day) Method of water removal from sludge Drying Bed/s ( ) VacuumFiltration ( ) Pressure Filtration ( ) Centrifugation ( ) If others, specify _______________ Method of Disposal Landfill inside the factory ( ) Landfill outside the factory ( ) Ocean dumping ( ) If others, specify ___________ I. HazardousWaste M anagement Method of disposal(specify): _______________________________________________________________ DENR ID Number as Hazw aste Generator: __________________ Date issued: ____________________ J. Vicinity Map I hereby certify that the information above are true, complete and accurate to the best of my know ledge. ________________________________________ _____________________________________ Name & Signature of the Pollution Control Officer Name & Signature of the Chief Executive Officer Date: _______________________________ Date: ___________________________ SUBSCRIBED AND SWORN to before me a NOTARY PUBLIC, this ______ day of ________________, affiant exhibiting to me his/her CommunityTax Receipt No. _________________ issued at ________________ on ___________________ NOTARY PUBLIC Doc. No. ________ Page No. ________ Book No. ________ Series No. ________ All information contained in this application form will be held strictlyconfidential. LLDA-CPD-Form 11 Issue Date: April 2015 Issue No.: 01

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