Affidavit Emb Denr Hazardous Waste Blank

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AFFIDAVIT

Republic of the Philippines )


City of Koronadal ) S.S.
South Cotabato )

I, _________________, of legal age, Filipino citizen, single, residing at


_________________________, the President of __________________________,
located at __________________; after being sworn in accordance with law, depose
and say that:

1. I am an applicant for registration as Hazardous Waste Generator pursuant to


Section 26 of RA 6969 (Toxic Substances and Hazardous and Nuclear
Wastes Control Act of 1990);

2. I am aware and understand all the duties, responsibilities and accountability


to be imposed upon me and my establishment by such application and as
such will be liable for all the damages incurred and for any untoward incident
during its actual operation, during generation of hazardous wastes and shall
be wholly responsible for spill response and clean-up during spills or
accidental leaks including clean-up or remediation of affected areas and
compensation for any environmental damage caused by such spill or leakage
of hazardous wastes;

3. I attest to the truth, accuracy and genuineness of all the information,


documents and records contained and attached to this application and that I
and my establishment shall be liable for any misrepresentation, fraudulent
declaration and all its consequences;

4. I am executing this affidavit as a proof of good faith in complying with the


requirements for securing the abovementioned registration.

IN WITNESS WHEREOF, I have hereunto set my hand this


______________________, in City of Koronadal, South Cotabato.

_________________
Signature over printed name of affiant

SUBSCRIBED AND SWORN to before me this _____________ in the City of


Koronadal, South Cotabato, Philippines with affiants exhibiting to me his Driver’s
license no. _____________ with his photograph appearing thereon sufficient to
establish his identity.

Doc. No.
Page No.
Book No.
Series of 2021.

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