LAGUNA LAKE DEVELOPMENT AUTHORITY

QUARTERLY SELF-MONITORING REPORT

1 2 3 4
Quarter Months Covered : __________________________

A. General Information
Name of the Plant

Plant Address Street No. & Street Name _______________________________________

(NOT the company or Barangay __________________ City or Municipality___________________

the head office) Province ___________________________________________________

Phone Number Fax Number

Type of Business TIN Number

Name of the PCO

Single Proprietorship Partnership Private Domestic Corporation

Legal Classification
Govt. Corporation Multi-national Other Specify ___________

Ownership in Terms of Private Domestic _____% Foreign _____% Government _____%

Equity Participation

Market Where Goods Domestic _______% Export _______%

are Sold

Is the Establishment Traded in the Stock Market? Yes No

If Yes, Under What Name: ___________________________________________

If the head office is not located at the above address, please fill-up

Name of the Company

Street No. & Street Name ______________________________________

Address Barangay _________________ City of Municipality _________________
Province ____________________________________

Phone Number _______________________________ Fax Number _________________________

Note:
Please observe the required frequency of analysis and submission of SMR
Flowrate Type Frequency Submission of SMR
0-150 m3/d BOD,conventional parameters Once every quarter Semi-Annualy
0-150 m3/d Hazardous waste Once every month Quarterly
> 150 m3/d BOD, conventional parameters Once every month Quarterly

LLDA-CPD-Form 17 Issue Date: April 2015 Issue No.: 01

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B. Wastewater Treatment Plant (WTP) Record
B.1 Average Duration of Time Operated & Ave. Volume of Discharge Per Day
Month 1 ___________, 200_ Month 2 ___________, 200_ Month 3 ___________, 200_
Day of the
Hours of Effluent Flow Rate Hours of Effluent Flow Hours of Effluent Flow Rate
Month 3 3 3
Operation m /day Operation Rate m /day Operation m /day
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Ave./Mo.
Were there any major interruptions in WTP operation? For example, due to equipment breakdown or major maintenance
procedures. Yes No . If yes, please attach explanation on separate page.

LLDA-CPD-Form 17 Issue Date: April 2015 Issue No.: 01

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B.2 Record of the Cost of Treatment

Operating Cost of the Wastewater Treatment Plant

Month 1________________ Month 2________________ Month 3________________

New or Additional Name of the Cost (pesos) Name of the Cost (pesos) Name of the Cost (pesos)
Investment Component Component Component
in the WTP

kwH Cost (pesos) kwH Cost (pesos) kwH Cost (pesos)

Energy Usage of the

WTP

Persons Employed Total Avg. Hrs. Total Cost Total Avg. Hrs. Total Cost Total Avg. Hrs. Total Cost
Full-time for the Number per Day (pesos) Number per Day (pesos) Number per Day (pesos)
WTP

Persons Employed Total Avg. Hrs. Total Cost Total Avg. Hrs. Total Cost Total Avg. Hrs. Total Cost
Part-time for the Number per Day (pesos) Number per Day (pesos) Number per Day (pesos)
WTP

Cost of Chemicals
Used by WTP (pesos)

Total Maintenance
Cost-repairs, spare
parts etc. (pesos)

Administrative and
Overhead Cost (pesos)

Laboratory Cost

Is there a laboratory in the factory premises? Yes No

Month 1________________ Month 2________________ Month 3________________

If Yes, monthly cost

of operating the
laboratory (pesos)

LLDA-CPD-Form 17 Issue Date: April 2015 Issue No. : 01

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C.1 Monthly Report of Wastewater Characteristics for Conventional Pollutants

Description of the Outlet: X-UTM ____________________________ Y-UTM ____________________________

Is this the only outlet for the wastewater: Yes No If No, please submit this report for other outlets also
Make a copy of this table if needed. For zero discharge scheme, you may not fill-up this page.

BOD COD TSS Color Temperature pH Oil & Grease Coliform

Date (mg/l) (mg/l) (mg/l) . (oC) . (mg/l) MPN/100ml)
Influent Effluent Influent Effluent Influent Effluent Influent Effluent Influent Effluent Influent Effluent Influent Effluent Influent Effluent

Ave./Mo.

Please attach Results of Laboratory Analysis (ROLA)

Name of the Laboratory
Address Phone

LLDA-CPD-Form 17 Issue Date: April 2015 Issue No.: 01

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C.2 Monthly Report of Wastewater Characteristics for Other Pollutants

Description of the Outlet: X-UTM ________________________ Y-UTM _______________________

Is this the only outlet for the wastewater: Yes No If No, please submit this report for other outlets also
Make a copy of this table if needed. For zero discharge scheme, you may not fill-up this page.

Effluent Parameter Name Parameter Name Parameter Name Parameter Name Parameter Name Parameter Name Parameter Name
Flow Rate in
______________ ______________ ______________ ______________ ______________ ______________ ______________
terms of
Date of: Cubic Unit _________ Unit _________ Unit _________ Unit _________ Unit _________ Unit _________ Unit _________
meters/day Influent Effluent Influent Effluent Influent Effluent Influent Effluent Influent Effluent Influent Effluent Influent Effluent

Please attach Results of Laboratory Analysis (ROLA)

Name of the Laboratory
Address Phone

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LLDA-CPD-Form 17 Issue Date: April 2015 Issue No.: 01

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D. Background Data
D.1 Sources of Wastewater during this Quarter

Generating Process Estimated Flow (m3/day)

Production Process
Washing/Cleaning
Cooling
Domestic Wastewater
Recyled/Reuse Water/Others

Total Volume of Discharged Wastewater

D.2 Employment and Operation Information

Total employment in the factory: Production Non-Production ________

Number of hours of production/day __ Number of days of production per/month __

Number of months of production/year _____

Total value of investment in the factory: (Pesos)____________________

Average Energy Consumption: Coal (tons) Gas (m3) Oil (m3) Electricity (kwh)
(please check monthly or annual) Monthly or Annual Monthly or Annual Monthly or Annual Monthly or Annual

Quantity

Value (Pesos)

D.3 Production Information - See Attached

Product 1 Product 2 Product 3 Product 4 Product 5

Product Name1

Max. Allowable
Production Capacity
per Year
Actual Average
Production per
Month

Type of Batch Batch Batch Batch Batch

Process
Continuous Continuous Continuous Continuous Continuous

1
Please use generic product name; not brand names.

LLDA-CPD-Form 17 Issue Date: April 2015 Issue No.: 01

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D.4 Water Pollution Information

INFORMATION ON DISCHARGE POINTS IN THE FACTORY

Outlet Location & Description Name of the Receiving Body if Not

Number of the Outlet Discharging Directly in the Lake

INFORMATION ON THE WASTE WATER TREATMENT SYSTEM

Is there an existing waste water treatment system? Yes No

If yes, what is the capacity of the waste water treatment system? ________cubic meter
Value of capital investment in the waste water treatment plant Pesos_______________
Is there a primary treatment system? Yes Year Installation
No Month_______Year____
If Yes, what is the composition of the physical treatment system?
Screening Equalization Grit Removal Oil-water separator
Sedimentation If other, specify______________________________________
Is there a chemical treatment process? Yes Year of Installation
No Month ______________Year________
If Yes, what is the composition of the chemical treatment system?
Adsorption Disinfection Flocculation/Coagulation pH Adjustment
If other, specify _______________________________________________________
Is there a secondary treatment system? Yes Year of Installation
No Month ______________Year________

If Yes, what kind of secondary treatment system is installed in the plant?

Activated Sludge Anaerobic & Aerobic Treatment Anaerobic Treatment

Oxidation/Stabilization Pond Rotating Biological Contactors Trickling Filter

Others, Specify : _______________

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D.5 FLOW METER INFORMATION

Is there a flow meter to measure the quantity of waste water Yes No

discharged from the plant?

What type of flow meter is used for measuring the wastewater discharge rate?
Rectangular Weir Triangular Weir Other Weirs Venturi Meters
Magnetic flow Meters Current Meters Flow Measurements
If other, please specify__________________________________
_______________________________________________________________________________

D.6 MANAGEMENT OF SLUDGE FROM WASTE WATER TREATMENT SYSTEM - N/A

Is the quantity of sludge large enough to require proper management? Yes No

Which method is used for removing water from the sludge?

Drying Beds Vacuum Filtration Pressure Filtration Centrifugation
If other, specify ___________________________________________________________________

How is the sludge dried? Heat Drying Incineration Wet Oxidation

If other, specify ___________________________________________________________________

How is the sludge disposed of?

Landfill inside the Landfill outside Ocean dumping
factory the factory
If other, specify ___________________________________________________________________

Submitted on Date ______________

Name and Signature of the Pollution Control Officer Name and Signature of the Chief Executive Officer

SUBSCRIBED AND SWORN to before me a Notary Public, This_____day of ___________________,

affiant exhibiting to me his/her Community Tax Receipt No.__________, issued at_________ on _______.

NOTARY PUBLIC

LLDA-CPD-Form 17 Issue Date: April 2015 Issue No. :01

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