Department of Environment and Natural Resources

Environmental Management Bureau

Reference No:

(to be filled up by DENR only)

____Quarter 20__

GENERAL INFORMATION SHEET

Name of the
GREEN EARTH METAL REFINING, INC.
Establishment/Facility
Street # & Street Name: LIBIS ST.,
Establishment/Facility
Address Barangay: SALUYSOY City/Municipality:
(NOT the company of MEYCAUAYAN CITY
head office)
Province: BULACAN
Name of
GREEN EARTH METAL REFINING, INC.
Owner/Company
Street # & Street Name: LIBIS ST.,
Address
(if address is not the Barangay: SALUYSOY City/Municipality:
same as previous MEYCAUAYAN CITY
address)
Province: BULACAN

Phone Number Fax Number

e-mail address [email protected]

Philippine Standard Industry Classification Code No. 07210 -

Type of Business/
Industry Classification Philippine Standard Industry Descriptor:

CEO/President. JENNIFER PERNIA

Tel #: Fax #:
e-mail address: [email protected] -
Responsible Officer/s:
Plant Manager:
Tel #: Fax #:
e-mail address:

Name.
Pollution Control Officer Tel #: Fax #:
e-mail address:

 single proprietorship  partnership

Legal Classification  private domestic corporation  government corporation
 Multi-national 

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

Name/Signature of CEO/President Name/Signature of PCO

Name of Plant: ___________________________________________________________________

 Reference No:

Department of Environment and Natural Resources

Environmental Management Bureau

QUARTERLY SELF-MONITORING REPORT

MODULE 1: GENERAL INFORMATION

Name of the Plant GREEN EARTH METAL REFINING, INC.
Please provide the necessary revised, corrected or updated information not contained in your General
Information Sheet

(use additional sheet/s if necessary)

DENR Permits/Licenses/Clearances
Environmental
Permits Date of Issue Expiry Date
Laws
A/C No.
P.D. 984
PO No.

ECC 1

PD 1586 ECC 2

ECC 3
DENR
Registry ID
CCO Registry
RA 6969 Importer
Clearance No
Permit to
Transport
A/C No.
RA 8749
PO No.

Module 1: General Information page ____ of ____

 Reference No:

Operation
Operating hours/day Operating days/week # of shift/day

Average

Maximum

Operation/Production/Capacity:
Average Daily Production
Total Output this Quarter
Output
Total Water Consumption Total Electric
this Quarter (cubic Consumption this Quarter
meters) (KwH)
Please use additional sheet/s if necessary

Module 1: General Information page ____ of ____

MODULE 2: RA 6969

A. CCO Report (please accomplish this section for each chemical/substance)

Common Name/IUPAC/CAS Index Name. ___

CAS No.: ___
Trade Name: ___

For importers only:

Import
Quantity Date of Quantity Country of Country of
Clearance Port of Entry
Requested Arrival Received* Origin Manufacture
No.

Total Quantity Requested Total Quantity Received

(annual) (annual)
* attach copy/s of Bill of Lading

For distributors (importers/non-importers)

Name of Client License No. Quantity Date of Distribution

Total Quantity Distributed

For non-importer users:

Name of Distributor Quantity Date of Purchase

Total Quantity Purchased from Distributor

For producers
Average Daily Production
Total Output this Quarter
Output
Quantity of Stock Quantity of Stock
Inventory (Start of Inventory (End of Quarter)
Quarter)

Module 2A: RA 6969 (CCO Report) page ____ of ____

 Name of Buyer Quantity Date of Purchase

Total Quantity Sold

Used in Production (please fill up only if chemical/substance is not main product)

Average Daily Production
Total Output this Quarter
Output
Average Quantity Used Total Quantity Used this
per month Quarter
Describe any changes in Production/Process/Operations:

Stock Inventory/Waste Chemical Generated:

Average Quantity of Total Quantity of Waste
Waste Chemical Chemical Generated this
Generated per month Quarter
Quantity of Stock Quantity of Stock
Inventory (Start of Inventory (End of Quarter)
Quarter)

Other Information:

Manner of handling  storage on-site  Treatment on-site

hazardous wastes  storage off-site  Treatment off-site

Changes in Safety  Yes (please attach copy of revised plan)

Management System  No

 Yes (please attach copy if not submitted/included in previous report/s or had been
Chemical Substitute revised)
Plan
 No

Module 2A: RA 6969 (CCO Report) page ____ of ____

B. Hazardous Wastes Generator

HW Generation:
Remaining HW from
HW HW Generated
HW No. HW Class HW Nature Previous Report
Cataloguing
Quantity Unit Quantity Unit

Waste Storage, Treatment and Disposal:(Please fill-up one table per HW)
HW No,: ___
HW Details Qty of HW Treated: Unit: ___
TSD Location: ___

Name: ___
Storage
Method: ___

ID: Name: ___

Transporter
Date: ___

ID: Name: ___

Treater
Method: Date: ___

ID: Name: ___

Disposal
Date: Date: ___

HW No,: ___
HW Details Qty of HW Treated: Unit: ___
TSD Location: ___

Name: ___
Storage
Method: ___

ID: Name: ___

Transporter
Date: ___

ID: Name: ___

Treater
Method: Date: ___

ID: Name: ___

Disposal
Date: Date: ___

On-Site Self Inspection of Storage Area:

Corrective Action Taken
Date Conducted Premises/Area Inspected Findings & Observations
(if any)

Module 2B: RA 6969 (Hazardous Wastes Generator) page ____ of ____

Module 2B: RA 6969 (Hazardous Wastes Generator) page ____ of ____
C. Hazardous Wastes Treater/Recycler

HW Stored and/or Untreated as of End of Quarter:

Type of
Transport Storage Time Table
HW Wastes Date of
Permit/Date Valid until Quantity Container/ for
Number Generator Transport
of Issue # of Treatment
containers

HW Treated and/or Recycled as of End of Quarter:

Type of Type &
Transport Treatment Quantity of
Type of HW Wastes Date of
Permit/Date Quantity or Recycled
Wastes Number Generator Transport
of Issue Recycling or Treated
Process Product

Residual Wastes Generated from the Treatment and/or Recycling Operation:

Type of
Process by
Storage
Type of which the Disposal Time Table
HW Number Quantity Container/
Wastes Wastes is Option for Disposal
# of
Generated
containers

Module 2C: RA 6969 (Hazardous Wastes Treater/Recycler) page ____ of ____

MODULE 3: P.D. 984 (Water Pollution)

Water Pollution Data

Domestic wastewater Process wastewater
(cubic meters/day) (cubic meters/day)
Cooling water Others: ___________
(cubic meters/day) (cubic meters/day)
Wash water, equipment Wash water, floor
(m3/day) (cubic meters/day)

Record of Cost of Treatment (Separate entries for separate facilities)

Month 1 Month 2 Month 3
Person employed, (# of
employees)
Person employed, (cost)
Cost of Chemicals used
by WTP
Utility Costs of WTP
(electricity & water)
Administrative and
Overhead Costs
Cost of operating in-
house laboratory

New/Additional
Investments in WTP
(Description)

Cost of New/Add
Investments

WTP Discharge Location

Outlet
Location of the Outlet Name of Receiving Water Body
Number
1

Module 3: P.D. 984 (Water Pollution) page ____ of ____

Detailed Report of Wastewater Characteristics for Conventional Pollutants
Outlet No.
________
Effluent Oil & (name)
BOD TSS Temp rise
DATE Flow Rate Color pH Grease
(mg/L) (mg/L) (ºC)
(m3/day) (mg/L)
(unit)

Please fill-up/accomplish separate form/s for other outlet/s.

Detailed Report of Wastewater Characteristics for Other Pollutants

Module 3: P.D. 984 (Water Pollution) page ____ of ____

 Outlet No.
________ ________ ________ ________ ________ ________ ________
Effluent (name) (name) (name) (name) (name) (name) (name)
DATE Flow Rate
(m3/day)
(unit) (unit) (unit) (unit) (unit) (unit) (unit)

Please fill-up/accomplish separate form/s for other outlet/s.

Please use additional sheet/s if necessary.

Module 3: P.D. 984 (Water Pollution) page ____ of ____

MODULE 4: R.A. 8749 (Air Pollution)

Summary of APSE/APCF
Process Equipment Location # of hrs of operations

1.

2.

3.

4.
Quantity # of hrs of
Fuel Burning Equipment Location Fuel Used
Consumed operations
1.

2.

3.

4.

5.

6.

Pollution Control Facility Location # of hrs of operations

1.

2.

3.

4.

Cost of Treatment
Month 1 Month 2 Month 3
Cost of Person employed,
(salary)
Total Consumption of
Water (cubic meters)
Total Cost of chemicals
used (e.g., activated
carbon, KMnO4)
Total Consumption of
Electricity (KwH)
Administrative and
Overhead Costs
Cost of operating in-
house laboratory, if any

Improvement or
modification, if any.
(Description)

Cost of improvement of
modification

Module 4: RA 8749 (Air Pollution) page ____ of ____

Detailed Report of Air Emission Characteristics
Description/Location
of PCF
________ ________ ________ ________
Flow Rate CO NOx Particulates (name) (name) (name) (name)
DATE
(Ncm/day) (mg/Ncm) (mg/Ncm) (mg/Ncm)
(mg/Ncm) (mg/Ncm) (mg/Ncm) (mg/Ncm)

Please fill-up/accomplish separate form/s for other PCF/s.

Please use additional sheet/s if necessary.

Module 4: RA 8749 (Air Pollution) page ____ of ____

MODULE 5: P.D. 1586

Ambient Air Quality Monitoring (if required as part of ECC conditions)

Description/Location
of Monitoring Station
________ ________ ________ ________
Noise CO NOx Particulates (name) (name) (name) (name)
DATE
Level (dB) (mg/Ncm) (mg/Ncm) (mg/Ncm)
(mg/Ncm) (mg/Ncm) (mg/Ncm) (mg/Ncm)

(Please accomplish one table per monitoring station.)

Ambient Water Quality Monitoring (if required as part of ECC conditions)

Description/Location
of Sampling Station
________ ________ ________ ________ ________ ________ ________ ________
(name) (name) (name) (name) (name) (name) (name) (name)
DATE
(unit) (unit) (unit) (unit) (unit) (unit) (unit) (unit)

(Please accomplish one table per sampling station.)

Module 5: P.D. 1586 (EIS System) page ____ of ____

Other ECC Conditions
Status of Compliance
ECC Condition/s Actions Taken
Yes No

1.

2.

3.

4.

5.

6.

7.
Please use additional sheet/s if necessary.

Environmental Management Plan/Program

Status of Implementation
Enhancement/Mitigation Measures Actions Taken
Yes No

1.

2.

3.

4.

5.

6.

7.
Please use additional sheet/s if necessary.

Solid Waste Characterization/Information:

Average Quantity of Solid Total Quantity of Solid
Wastes Generated per Wastes Generated this
month Quarter
Average Quantity of Solid Total Quantity of Solid
Wastes Collected per Wastes Collected this
month Quarter
Entity in charge of
collecting solid wastes

Brief Description of Solid

Waste Management Plan
(e.g., waste reduction,
segregation, recycling)

Module 5: P.D. 1586 (EIS System) page ____ of ____

 Procedural and Reference Manual for DAO 2003-27

MODULE 6: OTHERS

Accidents & Emergency Records

Findings and
Date Area/Location Actions Taken Remarks
Observation

Personnel/Staff Training
# of Personnel
Date Conducted Course/Training Description
Trained

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

Done this _________________________, in ________________________.

Name/Signature of PCO

Name/Signature of CEO

__________________________________________________
(Name of the Establishment/Facility)

SUBSCRIBED AND SWORN before me, a Notary Public, this ________ day of
______________________, affiants exhibiting to me their Community Tax Receipts:

Name CTR No. Issued at Issued on

_____________________ _____________ _______________ ______________
_____________________ _____________ _______________ ______________

Preparation and Submission of SMR 16