9ab-Tt, T: Loc?Dd3
9ab-Tt, T: Loc?Dd3
9ab-Tt, T: Loc?Dd3
Fnr
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( Proj ec t Pr-oponerr t )
P'ilLIECT
LffiftTII}I:
(ltlame of River. Lakes. Sea. etr.)
iltfis€ $F
Pft${MGNT ; l-Orlt> DG3 6ov pSr,1
ADDfIE$S:
J
( Comp I ete Address: S treet, Brgy. Mlrn. /C ,'ty /Prav . )
Ftur'
eMB'0FFICIAL
"{/
(T rn, v
l- Project ownership tI
single proprietorship ( ) Corporation ( ) partnership
(Attached documents as Annex I )
I
3. Project Objective i ITATIONALES
Presentation of projecl purpose and background (reason
why project is oroposed)
Presentation of need for the project at the national, regional
& locat level.
B. PROJECT DESCRIPTION
FILI
e!,tB'0FFlchL
{0
3. Mode of Extraction:
EQUTPMENTS CAPACITY/SOUIdCf,
(R.ented/Owned)
4. Pt'oof of (hvnership ovcr thc *djecent tr end (That is beside the river where
proposed extrection project loceted)
or TCT # I
.T / Emancipation Patent No
Homestand Patent No.
'angay
l. S&il VICENIE
SA N UA, NUET
Private
aaD. -
Road
EMB. OFFICIAL F E
34
C. DESCRIPTION OF' EXISTING ENVIRONIVT EI\T
(Rer4alksJo be filled-up the Proponent and DENR- Personnel who will conduct the site
evaluaTion/ocular inspection of the site)
l0O-300 masl
301-500 masl
501-1,00O masl
I
(to Ee determine evaluatioq refer to the
topSgraphic map where the evaluation per
contour line is indicated)
Boulders: no boulders
fine Sffi:r It sufficlent
Gravel: x sufflclen
. j..
tfal
the_arca expcrienced any flash flooding
FLE
g},lB.OFFICIAL
?a
#{
What kind of access road will be traversed.
irt road asPhalted cemented gravelled
-*-.others
What are the present uses of the water bodies within or near the extraction.
Are there any existing permittee(s) extrador(s) within 1 kilometer radius from proposed
site?
Yes-- No If yes how many state neme of all perrnittes
in additional sheet) Estimated volurne of extraction/hectare
BIOI,OGICAL VIRONI}IE NT
AN
COMPOIq ENT/PA RA M ElT RS l' N REMAR}(S
Proponent DEI{R.
Are the existing trees and other types of noI1o
I
vegetataion in the site and zurrounding
u,ithin 100 meters radius.
;
Fll F
F..!,{B-cFFlclAL
K
Birds and Otherc 'frees and Other Fistrery Resources
Wildlife huportant Vegetation
Itone exceot douestic crEL sse s Local fieh
fish uoual.Jy llving lbl.ahib varleties in the
in the rlver. I
river.
3. SOCIG.ECONOMIC
Fnoponent DENR
Arc thers ocisting settlements is near the site
(at least than I km. Radius.
Yes / No none
If 'YES" How many Flouseholds?
EMB. OFFICIAt
FIIL
1/
Additional rema rks/recom mendrtion of tl/e Inspcction Officer:
C.
Conlnrrncd.
tlt^"j;qE?LL
Loua-9 ES IN
Proponent
gMB.OFFICNL FII..B
YA'{ corumn )
- the negative in the
ffif,:,T,t[11iiliffi*i,3rT,fif#3,']".
proiecr'
pre'constructiort period on the SAG
Note: No
AFFECTING
PROJECT ACTTVITIES M
ImPrct Enhancement
Y N DcscriPtion
PHYSICAL ENVTRONMENT
I. I,AND
in:
Wiff rttt ProPosal result
a. compactio" .1",ilX}.iffi;il:L1,.
disPlacement ol
conditions?
condhions?
c. U;t.bi; earth conditions?
or geologic
i d. Change in the soil
$sbstructures?
or increase in wind
e. The continuation of
soils' either on or otT
or wder *"on'Jf
the site?
or erosion of
f. Changes in disposition
ffi*nA or changes in siltatiorl-.-
ffi;t,#r uo'io-n that maY modifY
ti'o or stream or bed of
ilffi;;;iof "
r lake?
I 2. AIR
Will th€ Project result in:
-Attl'd; or
e'
;. Po[ution emissions
air?
a"tetio*tibn of arnbient
tu )
v
Mitigetion/
lmpact
PHYSTCAL ENVIRONMENT Y N Enhancement
Description
Mersures
3. WATER
4. PLAI{TLITE
Will th€ proposal result in:
a. Removal of any vegetative cover or
other vegetation associated with critical
wildlife habitat?
FiU}
!MB. OFFICDL
4
v
{
Mitigation/
Impact
PHYSICAL f,NVIRONMENT Y N Enhaoccment
Dcscription
Measureg
5. ANIMAL I,IFE
a. Change in the diversity of species or
nunnbers of any species of animals
(birds, land, animals including reptiles,
fish and shellfish benthos organisms,
insects or micro fauna)?
6. SOCIGECONOMIC
7. TRANSFORTATION/
CICUII\TION
t-
kr
Impact Mitigation/
PH YSICAI, ENVIR.ONMENT Y Fi Enhenccment
Description
Measures
E. PUBLIC SERVICES
Will the proposal have an unplanned effect
upon, or result in a need for new or altered
governmental services in any ofthe
following areas:
a. Fire protection?
b. Police protection?
c. Schools
d. Parks or other recreational facilities?
e. Maintenance of public facilities, ponent ll
including roads?
x x rtake re I
f Other governmental services?
velllng.
9. ARCHEOLOGICAUHISTORICAL
Will the proposal result in an alteration of a
significant archeological or historical site"
structure object, or building?
;
L I
, {n
r .rn'
V
Impect
Mitigrtion/
PHYSI{IA L ENVIRON}TENT Y N 0nhrncement
Description
Meesures
PNOPONENTS COMMIT}IEN'TSI
Arc you comrnitting yourrelf to... Y N
l. Comply with existing environmental rules and regulations, guidelines and
i 2.
criteria?
comply with all mitigation and enhancernent measures that have bcen
identified in these reports? /
6.
t r8
IT v
rl
D.A
i\ Putacheck{ )htark
2. Vicinity Map
3. Location Map
4. Topographic MaP /
h 2*
ACCOUNTAB II,ITY STATEM ENT
lh,*);-
EDES 6 EPA
Proponent
Ml"N116FZ-
Title of Designation
,!il
i:'uu't
EetB'0FF|CIAu
4/'
A('ltNo\1' l.r l)( ;l\l l:N',l'
dav of l() ;tl
Bf,FORf, IVIE th is b *fL
]', appcared
\\'ilh Cont C-crtificale Nn.
-- _- isrucrl g'zt :lt
-qttZlSr.-
m--lt+aellxPrroL-elol ' tn hislher c:rl)A(rlv as
of
voluntary sct rnd de(d. anrl th c
,{nd aiknowledgment to mc t hat this !1lE is hisiher p{ 8es'
of
entily hc/she rePresents. This documenl, which consi$t written, is an ln rl
cnl
including the Prge on which this acknowlerlgm --.-
Environmental Exrmination ReP ort Checklist
.rFlCn
Nol:r i\rblic
i.:r-.'il;,
I)tlc. No.
l'agt No.
Dook No. -l
Series of
FiLn
EilB-0FFICIAL
,r
)