TOXIC CHEMICAL SUBSTANCES

Permits Required The use, storage, importation, sale, distribution, manufacture, transport or processing of a chemical substance not listed in the Philippine Inventory of Chemicals and Chemical Substances (PICCS) after December 31, 1993 requires a permit granted by the Department/Bureau. (Section 17, DAO 29, Rules and Regulations of R.A. 6969) The Chemical Control Order (CCO) issued for a priority chemical which poses an unreasonable risk or hazard to public health and environment. The CCO provides that its importer, manufacturer, including distributor or user for some, need to register and/or secure importation clearance from the Bureau. Any person, entity or premises involved in the treatment, storage, transport and disposal of such priority chemical-bearing or contaminated wastes are also required to be registered. (Sec. 20, DAO 29- Rules and Regulation of R.A. 6969 and relevant DAO-Chemical Control Order for specific substances and priority chemicals) All waste generators are required to notify or register with the Department the type and quantity of waste generated; and to secure permit for its transport and the premises for storage, treatment, recycling, reprocessing or disposal (Sec. 26, 27 and 30, DAO 29, Rules and Regulations of R.A. 6969) Finally, the importation and exportation of hazardous substances or wastes shall also obtain prior written approval from the Department or Bureau. (Sec. 31, DAO 29, Rules and Regulations of R.A. 6969).

A. For Toxic Substances and Chemicals (Title II):

EMB REGIONAL OFFICE

I. Small Quantity Importation (SQI) Clearance Certification for Small Quantity Importation is required prior to importation of small quantity (less than 1000 kg) pure chemical substances or component chemicals in percentage by weight of product, mixture not listed in the PICCS. Requirements: a. Accomplished and notarized application form b. Material Safety Data Sheet (MSDS). c. Submit PMPIN if amount exceeds SQI requirements The Regional Office shall a. Verify if the applied chemical components are in the PICCS, or in the PCL or in the CCO. b. Review the MSDS of the applied chemical components specifically, on the ecological and toxicological properties. c. Notify the applicant of its approval within (20) working days from date of receipt of the application.

d. Provide color coded copies of permits for the following: blueapplicant/importer, green-BOC, white-file copy of the regional offices (cc: EMB-CO) e. Reserve the right to request proof of compliance d uring the approved period. f. Monitor that the amount of the chemicals does not exceeds 1,000 kg/yr. Through the Bill of lading or Air Way Lading. g. Ensure that all information submitted on Small Quantity Importation (SQI) of chemicals under RA 6969 are held confidential and shall be disclosed only upon approval by the EMB Director. h. Submit Quarterly Report to the EMB-CO on issuance of SQI clearances.

Procedural Flow Small Quantity Importation (SQI) Clearance

Proponent A Screening Officer (Application Form + Requirements) ? ? ? Accomplished and notarized application form Material Safety Data Sheet Submit PMPIN if amount exceeds SQI requirements

Complete?

No

Yes Records (Receiving)

1 day

PCD-CMS
15 days evaluation* * - which may include inspection/sampling

PCD
2 days

ORD (Approval/Disapproval)
2 days

Records (Releasing)

Steps: a. The applicant submits filled-up application form and complete requirements for SQI Clearance. b. The Screening Officer of the Chemical Management Section (CMS) - PCD checks completeness of application - If complete, pay the required fees (P500.00/chemical) - If not complete return to the applicant c. Records section receives filled up application form and the complete requirements and forwards to CMS-PCD d. The CMS evaluates application, prepares report and forwards to Chief, Pollution Control Division (PCD) e. The Chief PCD reviews and recommends for issuance of SQI Clearance and forwards to Regional Director. f. The EMB Regional Director approves/disapproves the Clearance

Note: A maximum of twenty (20) working days is required for the processing and issuance of SQI Clearance from the submission of complete documents.

SMALL QUANTITY IMPORTATION (SQI) (Please type or print answers)

1. Type of application ? New ? Renewal (Previous EMB approval as Annex ______) Information on chemical importer in the Philippines Registered business name and complete address in the Philippines Name of contact person Designation Telephone Fax. E-mail 3. Type of importer ? Distributor ? End-user

2.

Country of origin Name of manufacturer Address of manufacturer 4. Information on chemical substance (subject of application) Chemical name CAS number Chemical/structural formula Product Name 5.

Country of Manufacture

Inventory status of substance (Check all applicable chemical inventories where the chemical substance is currently listed.) ? US TSCA ? Europe EINECS or ELINCS ? Australia AICS ? JAPAN MITI ? Canada DSL or NDSL ? Korea KECI ? China CICS ? Philippines not a PCL substance Information on product/mixture, containing the chemical substance Name of product/mixture (as it will appear on bill of lading) Concentration of SQI chemical in product/mixture (%) Allowed annual import volume of product/mixture based on ?1000 kg/yr limit (kg) Units of allowed import of product/mixture (e.g., gallons, drum, containers)

6.

7.

The Material Safety Data Sheet (MSDS) of the chemical substance is attached as Annex ______ Other attachments (Please specify.)

8. Signature over complete name of applicant

Date submitted:

9. Signature over complete name of EMB receiving officer

Date received:

10. Fees_______________________OR#_________________Date _________________

II.

Philippine Inventory of Chemicals and Chemical Substances (PICCS) Certification

PICCS Certification is issued upon request of the importers and manufacturers for whatever purpose it may serve. Purposely, for information of the Bureau of Customs upon entry of the chemicals listed in PICCS. Requirements: a. b. c. d. e. f. g. h. Application form Letter of request for PICCS Certification stating reasons for such request. Material Safety Data Sheet (in ISO Format). Chemical Name (IUPAC Nomenclature). Common and other names Trade Name Molecular Formula If a component of a product, please include ? Product name ? Other components of the product. i. Claims for confidentiality can be included.

Note: PICCS Certification can be made in the product name to facilitate dealings with the Bureau of Customs.

The Regional Office Shall: a. Check the chemical composition of the product from the Material Safety Data Sheet (MSDS) which should be in its ISO format (16 items MSDS) b. Verify the components chemical of the product in the PICCS together with its Chemical Abstract Service Registry Number (CAS RN). c. When no CAS RN is indicated, verify from other existing databases (internet or other reference materials such as UN publications, among others. d. Check whether the chemical is in the Priority Chemical Listing or subject to a Chemical Control Order (CCO). e. When the chemical components are in the PCL, refer to the EMB-Central office for the submission of Biennial Report and DENR Hazardous Waste ID no. f. When the chemical is subject under a CCO, refer to the specific DENR Administrative Order for registration and importation clearance requirements. g. When the chemical is not listed in both PCL and CCO, issuance of PICCS Certification maybe issued if requested by company. The PICCS Certification states that the chemical is in the PICCS, and is not a new chemical and can be imported without any Pre-Manufacture Pre-Importation notification from the EMB-Central Office. h. The PICCS Certification does not preclude other requirements from other Regulatory agencies like the Fertilizer and Pesticides Authority (FPA), Philippine Drug and Enforcement Agency (PDEA) Philippine National Police (PNP), Bureau of Food and Drug (BFAD), etc. i. Confidentiality should always be observed.

Procedural Flow
Philippine Inventory of Chemicals and Chemical Substances (PICCS) Certification

Proponent

A ? Application form ? Letter of request for PICCS Certification stating reasons for such request. ? Material Safety Data Sheet (in ISO Format). ? Chemical Name (IUPAC Nomenclature). ? Common and other names ? Trade Name ? Molecular Formula ? If a component of a product, please include o Product name o Other components of the product. ? Claims for confidentiality can be included.

Screening Officer (Application Form + Requirements)

Complete?

No

Yes Records (Receiving)

1 day

PCD-CMS
10 days evaluation* * - which may include inspection/sampling

PCD
2 days

ORD (Approval/Disapproval)
2 days
PICCS Certification - Records

Steps: a. The applicant submits filled-up application and complete requirements for PICCS Certification b. The Screening Officer of the Chemical Management Section (CMS) checks completeness of application - if compete, pay the required fees (P450.00/chemical) - if not complete return to the applicant c. The records section receives the filled up application form and the compete requirements and forwards to the CMS-PCD d. The CMS evaluates application, prepares report and forwards to the Chief, Pollution Control Division (PCD) e. The Chief PCD reviews and recommends for issuance of PICCS Certification and forwards to Regional Director. f. The EMB Regional Director approves/disapproves the Certification

Note: A maximum of fifteen (15) working days is required for the processing and issuance of PICCS Certification from the submission of complete documents.

PHILIPPINE INVENTORY OF CHEMICALS AND CHEMICAL SUBSTANCES (PICCS) APPLICATION FORM

(Please Type or Print Answers ) A. Company Profile
Name of Applicant/Company : ___________________________________ _____________________________________________________________ Business Address: _____________________________________________________________ _____________________________________________________________ Storage Facility /Plant Address (if different from the above ) _____________________________________________________________ Telephone No. : ____________________________ Facsimile No. : ____________________________ E-mail address : ____________________________ Contact Person : _____________________________ Designation : ______________________________ Category of Applicant : (Check one or more categories, as appropriate ) ? importer ? distributor ? user / manufacturer ? transporter of chemical ? others (pls. specify) _______________________________________ B. Chemical Information Name of Chemical* ________________________ ________________________ CAS Registry No. ___________________________ ___________________________

* In the absence of CAS Registry No., use the IUPAC Nomenclature Trade names/generic names are not acceptable C.
D.

Attachment: Material Safety Data Sheet (MSDS)

Certification: I certify that the data and information hereto stated in this form and attachments are true and correct. I understand that any false or misleading statements may result in permanent denial of my/my companys application or cancellation of my/my companys registration. Date of application Printed Name Title/Designation : _________________________________ : _________________________________ : _________________________________

Signature of Authorized Person : _________________________________

Fees___________________OR #_____________________Date___________

III.

Registration for Importer/User/Manufacturer/Distributor/Transporter of Chemicals under Chemical Control Order (CCO)

Registration Certificate is required for importer, user, manufacturer and transporter/distributor of those priority chemicals subjected to Chemical Control Order (CCO) such as Cyanide, Mercury, and Asbestos.

Requirements: a. Duly Accomplished and notarized CCO Application Form (as appropriate for Asbestos, or for Cyanide, Mercury b. Current receipt of Business/Mayors Permit c. SEC/DTI Registration Certificate d. Process/production flow chart for manufacturing operation e. Chemical Management Plan f. Photo documentation of the plants operation, storage facilities, etc.

The Regional Office shall:

1. Screen initially the completeness of the submission according to all the necessary documentary requirements i.e. payment of fees, relevant endorsements from Bureau of Fisheries and Aquatic Resources, Bureau of Mines and Geosciences. 2. Check compliance to the two environmental permits: Environmental Compliance Certificate (ECC) for storage facility and Permit to Operate (PO)for Anti Pollution Control Facilities. 3. Review the sufficiency of the documents according to the substantive Requirements that is, referring to the specific DENR Administrative Order for each subject Chemical Control Orders for Cyanide, Mercury, and Asbestos an Verify and inspect the storage facility and the existing practices as stated in the Submitted documents. Verify the requested volume of importation per annum and validate the truthfulness of the submitted registered users for importers.

4.

5.

Procedural Flow
Registration for Importer/User/Manufacturer of Chemicals under Chemical Control Order (CCO)

Proponent ? Screening Officer (Application Form + Requirements) ? ? ? ? * Complete? No ?

A Duly Accomplished and notarized CCO Registration Forms (as appropriate for Asbestos, or for Cyanide and Mercury) Current Receipt of Business/Mayors Permit SEC Registration Process/production flow chart for manufacturing operation Chemical Management Plan Results of air monitoring data at the workplace for manufacturing operation (for Asbestos only) Certification of liabilities of parties to compensate for damage to life and properties in case of emergencies and accidents. Photo documentation of the plants operation, storage facilities, etc.

Yes Records (Receiving)

1 day

PCD-CMS
20-25 days evaluation* * - which may include inspection/sampling

PCD
2 days

ORD (Approval/Disapproval)
2 days

Records (Releasing)

Steps: a. The applicant submits duly accomplished and notarized CCO Registration Form (appropriately for Cyanide, Mercury and Asbestos) complete with requirements b. The Screening Officer of the Chemical Management Section (CMS) checks completeness of application - if complete, pay the required fees (P2,250.00/chemical, renewal P1,450.00/chemical) - if not complete return to the applicant c. The records section receives the filled-up application form and the complete requirements and forwards to the CMS-PCD d. The CMS evaluates, conducts site inspection, prepares report and forwards to the Chief, Pollution Control Division (PCD) e. The Chief PCD reviews and recommends for issuance of Registration and forwards to Regional Director f. The EMB Regional Director approves/disapproves the Certification

Note: A m aximum of thirty (30) working days is required for the processing and issuance of Registration from the submission of complete documents.

CHEMICAL CONTROL ORDER REGISTRATION FORM

CYANIDE AND MERCURY APPLICATION f(Please Type or Print Answers )
1. 2. Name of Applicant/Company : ___________________________________ _____________________________________________________________ Category of Applicant : (Check one or more categories, as appropriate ) ? ? ? ? ? ? ? 3. importer distributor user transporter of chemical waste transporter waste treater waste disposer

Type of chemical(s) CAS No. and chemical compound (s) to be handled and the corresponding Chemical Abstract Service (CAS) No. _____________________________________________________________ _____________________________________________________________ Business Address: _____________________________________________________________ _____________________________________________________________ Storage Facility /Plant Address (if different from the above ) _____________________________________________________________ _____________________________________________________________

4.

5.

Telephone No. : ____________________________ Facsimile No. : ____________________________ E-mail address : ____________________________ Contact Person : _____________________________ Designation : ______________________________ Business Permit No. ________________ SEC Registration No. _________________ Validity Date ______________ Validity Date ______________ Region/City ___________ Region/City ___________

6. 7.

8. 9.

Annual Chemical(s) Requirement (kg or MT) ______________________ ____________________________________________________________ Status of Compliance to Environmental Permit

Date of issuance/ validity date ECC No. _______________ Permit to Operate Number air _______________ water ______________ 10. __________ __________ __________

Region/City ____________ ____________ ____________

Attachments (Please attach a photocopy of the following) Business Permit SEC Registration Chemical Management Plan Copy of Environmental Permits

11.

Certification: I certify that the data and information hereto stated in this form and attachments are true and correct. I understand that any false or misleading statements may result in permanent denial of my/my companys application or cancellation of my/my companys registration. Date of application : _________________________________ Signature of Authorized Person : _________________________________ Printed Name : _________________________________ Title/Designation : ________________________________

_____________________________________________________________________ DO NOT WRITE IN THIS SPACE Chemical(s) Applied For : ________________________________ Endorsement and Inspection Report Date:____________________ Information checked by : ________________________________ Fee : ________________ Official Receipt No. ___________ First Verification Date : _________________ Second Verification Date : _________________

ECCNo. _____________ PO. No.______________ REGION _____________ O.R. No. _____________

ASBESTOS REGISTRATION FORM I. GENERAL INFORMATION 1. COMPANY NAME_________________________________________________ OFFICE ADDRESS___________________________________________________ _______________________________________________________________ PLANT ADDRESS/STORAGE FACILITY (If different from the above) _________________________________________________________________ __________________________________________________________________ 2. TELEPHONE NUMBER ________________________________________________ FAX NUMBER ___________________________________________________ 3. CONTACT PERSON/DESIGNATION _________________________________________________________________ __________________________________________________________________ 4. CATEGORY OF APPLICANT/TYPE OF BUSINESS ? ? ? ? Importer Manufacturer Owner of industrial, commercial and institutional structures With sprayed-on and friable asbestos Waste Service Provider (transporter, treater, disposer)

5. STATUS OF COMPLIANCE TO ENVIRONMENTAL AND OTHER PERMITS Date Issued ? ? ? ? ? ? II Environmental Compliance Certificate Permit to Operate (air) Permit to Operate (water) TSD Permit SEC Registration Business Permit Validity Date

ASBESTOS SPECIFIC INFORMATION A. 1.

(For all categories, if applicable)

IMPORTATION/PRODUCTION INFORMATION AVERAGE -ANNUAL/QUANTITIES IMPORTED/DISTRIBUTED AND USED ________________________________________________________________

2. 3. 4.

QUANTITY OF PRODUCTS PRODUCED (In kilos/year) _________________ QUANTITY OF BULK ASBESTOS (In kilos/year) _______________________ LIST OF ASBESTOS CONTAINING PRODUCTS IMPORTED/DISTRIBUTED AND/OR MANUFACTURED ____________________________________ ________________ ton/kg. ____________________________________ ________________ ton/kg.
_______________________________________ _______________________________________ _________________ ton/kg. _________________ ton/kg.

5. 6.

TYPE OR VARIETY OF ASBESTOS _________________________________ PROCESS FLOW CHART AND TYPE OF ACTIVITY EXPOSED TO ASBESTOS (Use additional sheet, if necessary) QUANTITY OF ASBESTOS WASTE PRODUCED/GENERATED ANNUALLY/QUARTERLY ? Friable (In Kilos/year) _____________________ ? Non-Friable (In kilos/year) _________________

7.

III.

MANAGEMENT INFORMATION 1. 2. TOTAL NUMBER OF WORKFORCE ___________________

NUMBER & CATEGORY OF EMPLOYEES THAT MAY BE EXPOSED TO ASBESTOS RELEASES. ASSESS THE NATURE AND EXTENT OF EXPOSURE TO ASBESTOS (INCLUDE MAXIMUM NUMBER OF WORKERS AND MAXIMUM HOURS PER DAY OF EXPOSURE AND ANY MEDICAL SUPERVISION OF PERSONS WHO ARE EXPOSED TO ASBESTOS) ________________________________________________________________ EDUCATION AND TRAINING PROGRAM ORGANIZED FOR ASBESTOS HANDLING OVER THE LAST THREE YEARS (NO.) __________________ DETAILS OF THOSE TRAINING PROGRAMS ORGANIZED?

3.

Title/Name _________________________ _________________________ _________________________ _________________________ IV.

Organizer ____________________ ____________________ ____________________ ____________________

Date/Duration ________________ ________________ ________________ ________________

PREVENTIVE AND CONTROL MEASURES 1. DESCRIBE THE GENERAL PREVENTIVE AND CONTROL PROGRAM OF THE COMPANY FOR ASBESTOS INCLUDING ITS VENTILATION SYSTEM. ______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________

2. DESCRIBE HOUSEKEEPING PRACTICES DEVELOPED AND IMPLEMENTED ________________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ ________________________________________________________________________ 3. IDENTIFY & DESCRIBE EQUIPMENT USED _______________________________________________________________________ _______________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ 4. LIST OF RESPIRATORY PROTECTIVE EQUIPMENT AVAILABLE FOR PERSONNEL/WORKER DURING HANDLING AT THE PREMISE AND DURING TRANSPORTING. ________________________________________________________________ _______________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ 5. DESCRIBE IN BRIEF THE CONTINGENCY PROCEDURES/PLAN (In case of emergency) _______________________________________________________________________ ________________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ V. TREATMENT, STORAGE & DISPOSAL INFORMATION (For all categories) 1. DESCRIBE STORAGE METHODS, PROCEDURES, FACILITIES AND LOCATION. ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ 2. DESCRIBE PROCEDURES FOR TRANSPORTATION OF RAW FIBER AND FINISHED PRODUCTS. ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ _______________________________________________________________________ 3. ANY PLANNED RENOVATION(S) AND/OR REMOVAL OR MAJOR IMPROVEMENTS TO BE MADE IN THE NEXT 12 MONTHS? o Yes o No

4. LIST OF ATTACHMENTS 0 Pertinent Environmental Permits 0 Process Flow Chart 0 Results of air monitoring data of asbestos 0 Bill of Lading of all shipment per year 0 Certification of liabilities of parties to compensate for damage to properties and life incase of emergencies & accidents.. 0 Photo documentation of the plant's operation, storage facilities and others.

VI.

NOTARIZED CERTIFICATION THE UNDERSIGNED CERTIFY THAT THE INFORMATION PROVIDED IN THIS FORM IS TRUE AND ACCURATE. NAME ___________________________________ DESIGNATION/POSITION___________________

SIGNATURE______________________________DATE________________________

I acknowledge that this application form is a legally binding document, and I declare, under the penalties of perjury, that the same has been accomplished in good faith, verified by me, and, to the best of my knowledge and belief, is true and correct pursuant to the regulations issued under authority thereof.

____________________________ (Notary Public)

IV. Importation Clearance and Its renewal under Chemical Control Order (CCO) (Cyanide, Mercury and Asbestos) Requirements: a. Duly accomplished Application Form for Cyanide, Mercury and Asbestos by the concerned Importers, Manufacturers and Distributors. b. Registration Certificate for Cyanide, Mercury and Asbestos c. Bill of Lading or Airway Lading d. Copy of results of air monitoring data at the workplace for manufacturing operation for Asbestos only. e. Certification of liabilities of parties to compensate for damage to life and properties in case of emergencies and accidents. (as attachment to the form,) f. Bureau of Fisheries and Aquatic Resources Endorsement for Cyanide Importer only g. Bureau of Mines and Geosciences Endorsement for Mercury Importer only h. List of registered distributors/users for Importer of Cyanide and Mercury only. The Regional Office shall:

1. Screen initially the completeness of the submission according to all the necessary documentary requirements i.e. payment of fees, relevant endorsements from Bureau of Fisheries and Aquatic Resources (for Cyanide importers), Bureau of Mines and Geosciences (for Mercury importers) and Registration Certificate and the above-mentioned requirements. 2. Check compliance to the two environmental permits: Environmental Compliance Certificate (ECC) for storage facility and Permit to Operate (PO) for Anti Pollution Control Facilities.

3. Review the sufficiency of the documents according to the substantive requirements that is, referring to the specific DENR Administrative Order for each subject Chemical Control Orders for Cyanide, Mercury, Asbestos and Ozone Depleting Substances 4. Verify and inspect the storage facility and the existing practices as stated in the submitted documents.

5. Review the results of air monitoring data at the workplace for manufacturing operation for Asbestos only). 6. Verify the requested volume of importation per annum and validate the truthfulness of the submitted registered users list from the previous submissions and quarterly reports from other EMB Regional Offices i.e. in Cebu, Davao, National Capital Region, Region IV -A (CALABARZON), among others through the Focal Points. Consider the compliance to the Terms and Conditions of the CCOs Registration Certificate and other post requirements as required i.e. Bill of Lading/Airway Lading and Notice of Commencement.

7.

Procedural Flow
Importation Clearance under Chemical Control Order (CCO) (Cyanide, Mercury and Asbestos)

Proponent ? Screening Officer (Application Form + Requirements) ? ? ? Complete? No ? ?

A Registration Certificate for Cyanide, Mercury and Asbestos by the concerned Importers, Manufacturers and Distributors. Verification of the requested volume of importation per annum in relation to the issued Registration Certificate. Bill of Lading, Airway Lading and other post condition requirements Bureau of Fisheries and Aquatic Resources (BFAR) Endorsement For Cyanide importer only Bureau of Mines and Geosciences Endorsement for Mercury only. List of registered users for Cyanide and Mercury only.

Yes Records (Receiving)

1 day

PCD-CMS
15 days evaluation* * - which may include inspection/sampling

PCD
2 days

ORD (Approval/Disapproval)
2 days

Records (Releasing)

Steps: a. Importer/applicant submits duly accomplished form together with the complete requirements; b. The Screening officer of the CMS-PCD checks completeness of application - if complete, pay the required fees (P700.00/chemical) - if not complete return to the applicant c. EMB Records Section receives filled-up application form with complete requirements and forwards to CMS-PCD; d. CMS-PCD evaluates, prepares report and forwards to Chief; Pollution Control Division (PCD) e. The PCD Chief reviews and recommends approval to the Regional Director f. The EMB Regional Director approves/disapproves clearance.

IMPORTATION CLEARANCE FOR CHEMICALS WITH CHEMICAL CONTROL ORDERS OF CYANIDE, MERCURY AND ASBESTOS
Date Applied Application Control Number Official Receipt Number : _____________ : _____________ : __________________

Registry Reference Code ______________________ Date Issued _________________________________ I. II. III. IV. V. Applicants Name:___________________________________________________________________ Business Address: __________________________________ Contact Person: ___________________________________ Contact Number: ______________ Contact Number: ______________

Position / Designation: ________________________________ Fax Number: _________________ Type of Importer / Distributor of: ____________________________________ Storage Facility Address: _________________________________ Contact Number: ______________

VI.

Environmental and Other Permits Issued ECC No. ______________ PO No. ______________ Business Permit No. ______________ List of Importers / End-users Storage Facility Address: _________________________________ Contact Number: ______________ Storage Facility Address: _________________________________ Contact Number: ______________ Storage Facility Address: _________________________________ Contact Number: ______________ Storage Facility Address: _________________________________ Contact Number: ______________ Storage Facility Address: _________________________________ Contact Number: ______________ Storage Facility Address: _________________________________ Contact Number: ______________ Storage Facility Address: _________________________________ Contact Number: ______________

VII.

VIII

Data on Substance Subject to Importation:

Brand / Trade / Commercial Name ______________________________________ ________ Quantity (in kg): ________________________ Intended Use: _______________________________________________________________________

IX

Shippers Information / Transaction Data Country of Origin __________________________________________ Name of Exporting Company ___________________________________________________________ Business Address ___________________________________________________________________ Mode of Shipment (by air/by sea) _______________________ Expected Port of Entry/Loading _________________________________ Port Address _______________________________________________________________________ Expected Date of Arrival ____________________

X.

Present Inventory of Same Substance Subject for Importation (under applicants custody) Quantity (in kg): __________________________ Size of Storage Area (in m 2): ___________________

XI.

Attachments : Certificate of Accountability, Proporma Invoice and other documents as required in the Permits Terms and Conditions Fees__________________OR #__________________ Date___________________

XII.

I acknowledge that this application form is a legally binding document, and I declare, under the penalties of perjury, that the same has been accomplished in good faith, verified by me, and, to the best of my knowledge and belief, is true and correct pursuant to the regulations issued under authority thereof. ___________________________________ (Authorized Signature over Printed Name)

EMB CENTRAL OFFICE

I. Pre-Manufacturing and Pre-Importation Certification/ Interim Status Permit Notification (PMPIN)

The chemical or chemical substance subject of manufacture or importation needs prior notification/registration, and the corresponding PMPIN Certification issued at least Ninety (90) to One Hundred Eighty (180) days from the time of submission of complete requirements. Under special circumstances, the EMB Central may issue an interim status permit (ISP) for import or manufacturer of a new chemical. This will be issued only to manufacturers and importers of new chemicals provided that the premise has completed and submitted the appropriate PMPIN form and paid the fee at the time of notification. Requirements: a. Duly accomplished PMPIN Form (Abbreviated or Detailed as appropriate pursuant to Sec. 15, DAO 29) (Forms A are as shown below) b. Material Safety Data Sheet (MSDS) c. Certification/Relevant Studies as attachments to the PMPIN Form.

PROCEDURAL FLOW: Pre-Manufacturing and Pre-Importation Notification (PMPIN) Certification

Proponent Fill up forms notarized and complete the requirements ? ? ?

A Duly accomplished PMPIN Form (Abbreviated or Detailed as appropriate) Material Safety Data Sheet (MSDS) Certification/Relevant Studies as attachments to the PMPIN Form.

Screening Officer checks completeness and sufficiency

Records (Receiving)

EQD-CQMS Schedule for Chemical Review Committee Meeting

Reviews of submitted documents by Inter agency Chemical Review Committee

EQD - CMS Additional Information

No

Director, EMB Approval and Issuance of PMPIN Certificate

Yes

Proponent Submit Additional Information

Steps: a. The applicant submits a duly accomplished and notarized PMPIN Form (Abbreviated or Detailed as appropriate) in four (4) copies with the prescribed requirements as stated above. b. The Screening Officer of the Chemical Management Section (CMS) checks completeness of the application/notification: - If complete, pay the required fees (Abbreviated form P2,150.00/che mical, Detailed form P3,750.00/chemical) - If not complete return to applicant c. The Record Officer receives the application and forwards to Environmental Quality Division (EQD) d. The EQD-CMS schedules a meeting of the Chemical Review Committee (CRC). The CRC review PMPIN documents and subsequent additional information as requested. e. CRC recommends approval of PMPIN Certification to the Director f. EMB Director approves/disapproves PMPIN Certification

Note: A maximum of one hundred eighty (180) working days is required for the processing and issuance of the PMPIN Certification.

FORM A: PMPIN ABBREVIATED FORM Section A: Premise Information 1. Premise Name (in case of joint submission, the principal premise is required to complete this section) 2. Premise Physical Location and Telephone Number 3. Name of the Responsible Authority CBI ( )

4. Mailing Address and Telephone/Fax Number 5. Circle: Manufacture Import

Section B: Chemical Identification Information 6. Chemical Name: CAS Registry Name 7. CAS Number (if available) 8. RTECS Number (if available) 9. Molecular Formula 10. Synonyms for the New Chemical 11. Trade Name of the New Chemical Section C: Production, Import and Intended Use 12. Total quantity produced or imported in the first 12 months (Kg) 13. Estimate the quantity of the new chemical used in any of the following categories (kg): Site Limited Industrial Commercial Consumer IUPAC Common Name

CBI ( )

CBI ( )

Section D: Regulatory Status in Other Countries 14. Country Name: 15. Regulatory Status of the New Chemical in that country: 16. Is MSDS available for the new chemical in the country referred: No Yes (attach MSDS)

(Use a separate page if there are more than one country)

PMPIN ABBREVIATED FORM

Section E: Statement on Physicochemical Characteristics (if available) Boiling Point Melting Point S. Gravity Coefficient Solubility in Water Vapor Pressure Purity Water/Octanol Partition

Section F: Statement on Toxicological Effects of the Chemical

(Refer to instruction for the type of test results required)

Section G: Statement on Environmental Effects of the Chemical

Section H: List other companies and their address if this is a joint submission Section I: List of Attachments Certification: I hereby certify that all the information provided in this form and the support documents attached are true and accurate. Signed: Name: Position: Date:

PMPIN ABBREVIATED FORM INSTRUCTIONS

Confidential Business Information (CBI) Mark X if you claim CBI for any of sections: A,B, or C. Please provide in separate page justification for claiming CBI and attach. Section A Fill in the information about the premise/firm that is considered the principal submitter of this form. Section B Provide the chemical identity information. Consult DENR if you need assistance in obtaining the information required. It will expedite the review process if synonyms or analogues to the new chemicals can be presented. Otherwise attach the results of an X-ray diffraction (non-organic chemicals) or Mass Spectrum (organic chemicals) analysis to enable DENR review committee for correct identification of the chemical notified. Section C Estimate the total quantity of new chemical to be manufactured or imported during the first 12 months of operations. Under subsection 13 estimate how much of the intended production or import will be used in any of the four categories on an annual basis (the total should be equal to the figure provided in subsection 12). Industrial use is defined as any use during manufacturing and process operations. Commercial use is interpreted as any use aiming at consumer services. Section D Submission of the Abbreviated Form is primarily based on the premise that the new chemical is used in another country with a similar chemical review process as in the Philippines. It is important that the notifier provides all the information required in this section to expedite the review process. Section E Provide any document describing the physicochemical characteristics of the new chemical notified. Documented research data from other countries will be helpful. Notifiers with such information will assist DENR to expedite the review process. Section F Present a short description of potential toxicological effects of the new chemical (if any) and provide any document describing those effects. Documented research data and journal articles from other countries will be helpful. Health effects data may include carcinogenicity, sensitization, acute toxicity and irritaation. Notifiers with such information will assist DENR to expedite the review process. Section G Present a short description of potential environmental effects of the new chemical (if any) and provide any document describing those effects. Documented research data and journal articles from other countries will be helpful. Environmental effects may include acute and chronic toxicity to animals (fish in particular) and terrestrial plant toxicity. Information concerning the fate of the chemical upon release to environment will be important. Notifiers with such information will assist DENR to expedite the review process.

PMPIN DETAILED FORM

Section F: Statement on Toxicological Effects of the Chemical 14. Country Name: 15. Regulatory Status of the New Chemical in that country: 16. Is MSDS available for the new chemical in the country referred: Yes (attach MSDS) No

(Use a separate page if there are more than one country) Section G: Physiochemical Test Results 17. Tests Conducted by (Name and Address of the Laboratory): 18. Test Results Attached Yes No

(Refer to instruction for the type of test results required) Section H: Toxicological Effects Test Results 19. Tests Conducted by (Name and Address of the Laboratory) 20. Test Results Attached Yes No

(Refer to instruction for the type of test results required) Section I: Environmental Effects Test Results 21. Tests Conducted by (Name and Address of the Laboratory) 22. Test Results Attached Yes No

(Refer to instruction for the type of test results required) Section J: List other companies and their address if this is a joint submission

Section K: List of Attachments

Certification: I hereby certify that all the information provided in this form and the support documents attached are true and accurate. Signed: Name: Position: Date:

Confidential Business Information (CBI) Mark X if you claim CBI for any of sections A, B, or C. Please provide in separate page justification for claiming CBI and attach. Section A Fill in the information about the premise/firm that is considered the principal submitter of this form. Section B Provide the chemical identity information. Consult DENR if you need assistance in obtaining the information required. The results of an X-ray diffraction (non-organic chemicals) or Mass Spectrum (organic chemicals) analysis must be submitted along with this form to enable DENR review committee for correct identification of the chemical notified. Section C Estimate the total quantity of new chemical to be manufactured or imported during the first 12 months of operations. Under subsection 13 estimate how much of the intended production or import will be used in any of the four categories on an annual basis (the total should be equal to the figure provided in subsection 12). Section D (not applicable to importers) Estimate the type of activities the workers will be engaged in the use and production of the new chemical. For each type of activity provide information about the maximum number of workers and maximum hours per day that they will be exposed to the new chemical. Section E (not applicable to importers) Estimate the quantity of the new chemical that will possibly be released through air, surface water, groundwater, and soil. Also, provide a brief statement regarding release control measures planned. Section F Submission of the information concerning the regulatory status of this chemical in other countries will expedite the review process. Section G Provide any test results on the physicochemical characteristics of the new chemical notified. Documented research data from other countries will be helpful. Notifiers with such information will assist DENR to expedite the review process. The test results should include: Boiling Point, Vapor Pressure, Melting Point, Purity, S. Gravity, Water/Octanol partition Coefficient, Solubility in Water, and solubility in organic compounds. Section H Present the test results of potential toxicological effects of the new chemical and provide any document describing those effects. Submit documented research data and journal articles from academia in the Philippines and other countries. When you submit the test results, ensure that the full name and address of the laboratory which conducted the tests in the Philippines or in other countries are clearly indicated. The health effects data may include carcinogenicity, mutagenicity, teratogenicity, sensitization, acute and chronic toxicity and irritation. Notifiers with such information will assist DENR to expedite the review process. DENR may require full meeting of the new chemical notified if it determines that the information submitted is not adequate to assess the potential risk of the new chemical. Section I Present the test results of potential environmental effects of the new chemical and provide any document describing those effects. Submit documented research data and journal articles from academia in the Philippines and other countries. When you submit the test results ensure that the full name and address of the laboratory which conducted the tests in the Philippines or in other countries are clearly indicated. Environmental effects may include acute and chronic toxicity to animals (fish in particular) and terrestrial plant toxicity. Information concerning the fate of the chemical upon release to environment will be important and must be submitted if available. Notifiers with such information will assist DENR to expedite the review process. DENR may require full testing of the new chemical notified if it determines that the information submitted is not adequate to assess the potential risk of the new chemical.

II.

Certificate of Registration for the Importation of Ozone Depleting Substances (ODS) and Alternative Chemical Substance

Any person, natural or juridical, who imports ozone-depleting substance (regardless of source as allowed under agreements of the Montreal Protocol) in any of the forms defined under Article I paragraph 4 of the Montreal Protocol as clarified under Decisions I/12A and II/4, respectively, of the First and Second Meetings of the Parties, and with respect to any industry or activity of which list was derived from Annex D of the Montreal Protocol must be duly registered with and may be granted a Certificate of Registration by DENR-EMB. (Sec. 4, DAO 2000-18, CCO for ODS)

Requirements: a. b. c. d. e. f. Duly accomplished Application Form for Registration (shown below) ECC SEC Registration or DTI Registration Certification as to capability on effective Handling and Storage of Chemicals Certificate of Awareness on Ozone Layer Material safety Data Sheet (MSDS)

PROCEDURAL FLOW Registration for the Importation of Ozone-Depleting Substances and Alternative Chemical Substances

Republic of the Philippines Department of Environment and Natural Resources ENVIRONMENTAL MANAGEMENT BUREAU

PHILIPPINE OZONE DESK

2nd Floor, Human Resources Development Training Center DENR compound, Visayas Avenue, Diliman, Quezon City
Tel. Nos.: 925-2344 / 928-1244 E-mail Add.: [email protected]

APPLIC AT ION FOR REGIST RAT ION FOR THE IM PORT AT ION OF OZONE-DEPLET ING SUBST ANCES AND ALT ERNAT IVE CHEM ICAL SUBST ANCES
Important Note: Accomplish this form in three (3) copies, each with a photocopy of the previous EMB Certificate of Registration for the Importation of ODS and Alternative Chemical Substances (if applicable). To facilitate processing, all information must be supplied accurately.

Date Applied Registration Number Document Number

: _____________ : _____________ : _____________

I. II. III.

Applicants (Juridical) Name: _______________________________________________________________ Business Address: _________________________________________ Contact Number: ______________ Point Person Position / Designation : __________________________________ Contact Number: ______________ : __________________________________

IV.

Training / Seminar / Workshop Attended by the Point Person (attach a photocopy of the Certificate) Date: _________________ Title of Training / Seminar / Workshop: _______________________________________ Conducted by: _____________________

V. VI.

SEC / DTI Registration Number (attach a photocopy of SEC/DTI Registration Certificate with list of officers): ______________________________________________________________________________________ Type of Importer: (please mark X the appropriate box/boxes and fill-up the fields corresponding to it/them) Importer - Distributor Address of Storage Facility: __________________________________ Contact Number: ______________ Importer - End-user Address of Storage Facility: __________________________________ Contact Number: ______________

VII. VIII. IX.

Environmental Compliance Certificate (ECC) / Certificate of Non-Coverage (CNC) Number (attach a photocopy of the ECC / CNC): _____________________________________________________________ Profile of Business: ______________________________________________________________________ Data on Substance Subject to Importation: Brand / Trade / Commercial Name/s (attach the appropriate Material Safety Data Sheet or MSDS for each): ______________________________________________________________________________________ Intended Use: __________________________________________________________________________ (please mark X the appropriate box and fill-up the fields corresponding to it) Substance of Single Chemical Composition Generic Name: _____________________________ Chemical Formula: _____________ Substance of Multiple Chemical Composition Blend Generic Name: __________ Percent: ______ Generic Name: _____________________________ Chemical Formula: _____________ Percent: ______ Generic Name: _____________________________ Chemical Formula: _____________ Percent: ______ Generic Name: _____________________________ Chemical Formula: _____________ Percent: ______ Generic Name: _____________________________ Chemical Formula: _____________ Percent: ______ Generic Name: _____________________________ Chemical Formula: _____________

X. XI. XII.

Size of Storage Area (in m 2): ______________________________________________________________ Chemical Handler: __________________________ Position / Designation: ________________________

Training / Seminar / Workshop Attended by the Chemical Handler (attach a photocopy of the Certificate) Date: Title of Training / Seminar / Workshop: Conducted by: _________________ _______________________________________ _____________________ Fee: _____________ OR # __________________________ Date: ____________________

XIII

I acknowledge that this application form is a legally binding document, and I declare, under the penalties of perjury, that the same has been accomplished in good faith, verified by me, and, to the best of my knowledge and belief, is true and correct pursuant to the regulations issued under authority thereof. __________________________________ (Authorized Signature over Printed Name)

Steps: a. Importer applicant submits duly accomplished Application Form for Registration together with the complete requirements; b. Screening Officer checks the filled up application and the complete requirements - if complete pay the required fees (P2,250.00/chemical) - if not complete return to the applicant c. EMB Records Section receives filled up application form and complete requirements and assigns Document No. and forwards to Philippine Ozone Desk (POD); d. POD evaluates/processes application, prepares Certificate of Registration and submits to EMB- Environmental Quality Division (EQD); e. The EMB-EQD further reviews and recommends issuance Certificate of Registration to the EMB Director f. EMB Director approves/disapproves Certificate of Registration

Note: The applicant also submits requirements for Pre-Shipment Importation Clearance (PSIC) simultaneously Maximum of fifteen (15) working days for processing of the Certificate of Registration

III. Pre-shipment Importation Clearance of Ozone-Depleting Substances (ODS) And Alternative Chemical Substances The substances listed as Annex C and Annex E of the Montreal Protocol are not covered by the control measures and phase-out schedules provided under Section 3 of the CCO for ODS until such time that the Senate of the Philippines ratifies the amendments and adjustments to the Protocol. However, any importation of these substances (Annex C and E) is subject registration and issuance of Pre-Shipment Importation Clearance from the EMB prior to entry in any area within the Philippine Territory. (Sec 2.2 and 6, DAO 2000-18: CCO for ODS) Requirements: a. A copy of approved Certificate of Registration (per chemical substance), for old applicant; if new applicant, apply for a Certificate of Registration for Importation of ODS b. Form A (Application for Pre-shipment Importation Clearance of ODS and Alternative Chemical Substances) attached with Pro-forma Invoice c. Form B (Record of actual Arrival of Shipment, RAAS) with Bill of Lading and Commercial Invoice d. Form C (Summary of Transaction for Previous Inventory and Immediately Proceeding Importation of Same Substance) e. Form D (List of Intended Buyers and/or Users) f. Copy of Material Safety Data Sheet (MSDS) g. Certificate of Conformance from the DTI Bureau of Product Standards for alternative or substitute substances

PROCEDURAL FLOW. Pre-shipment/Importation Clearance for Ozone-Depleting Substances (ODS) Alternative Chemical Substances

Steps: a. Importer applicant submits duly accomplished Forms (A, B, C, D) together with the aforementioned requirements; b. Screening officer of POD checks the filled-up application and the complete requirements: - if complete, pay the required fees (P700.00/chemical) - if not complete return to the applicant c. EMB Records Section receives application form with complete requirements and assigns Document No. and forwards to Philippine Ozone Desk (POD); d. POD evaluates applications, prepares report and forwards to Chief; Environmental Quality Division (EQD) e. The Chief, EQD further reviews and recommends approval to the EMB Director f. EMB Director approves/disapproves clearance.

Republic of the Philippines Department of Environment and Natural Resources ENVIRONMENTAL MANAGEMENT BUREAU

PHILIPPINE OZONE DESK

2nd Floor, Human Resources Development Training Center DENR compound, Visayas Avenue, Diliman, Quezon City
Tel. Nos.: 925-2344 / 928-1244 E-mail Add.: [email protected]

FORM A
APPLIC AT ION FOR PRE-SHIPM ENT IM PORT AT ION CLEARANCE OF OZONE-DEPLET ING SUBST ANCES AND ALT ERNAT IVE CHEM ICAL SUBST ANCES

Original Copy
Important Note: Accomplish this form in three (3) copies, each with a photocopy of Proforma Invoice. To facilitate processing, all information must be supplied accurately. Please take note of the correct units of measure for each entry. For clarification and/or additional information, do not hesitate to contact POD- EMB-DENR.

Date Applied Proforma Invoice Number Application Control Number Document Number

: _____________ : _____________ : _____________ : _____________

I. II. III.

Applicants (Juridical) Name: _______________________________________________________________ Business Address: _________________________________________ Contact Number: ______________ Point Person Position / Designation : __________________________________ Contact Number: ______________ : __________________________________

IV.

Type of Importer: (please mark X the appropriate box/boxes and fill-up the fields corresponding to it/them) Importer - Distributor Address of Storage Facility: __________________________________ Contact Number: ______________ Importer - End-user Address of Storage Facility: __________________________________ Contact Number: ______________

V.

Data on Substance Subject to Importation:

Brand / Trade / Commercial Name: _________________________________________________________ Quantity (in kg): __________________________Purchase Price (in $ / kg): _____________________ Intended Use: __________________________________________________________________________ (please mark X the appropriate box and fill-up the fields corresponding to it) Substance of Single Chemical Composition Generic Name: _____________________________ Chemical Formula: _____________ Substance of Multiple Chemical Composition Blend Generic Name: ___________

Percent: ______ Generic Name: _____________________________ Chemical Formula: _____________ Percent: ______ Generic Name: _____________________________ Chemical Formula: _____________ Percent: ______ Generic Name: _____________________________ Chemical Formula: _____________ Percent: ______ Generic Name: _____________________________ Chemical Formula: _____________ Percent: ______ Generic Name: _____________________________ Chemical Formula: _____________

VI.

Transaction Data:

Name of Manufacturing Company: __________________________________________________________ Business Address: _________________________________________ Contact Number: ______________ Name of Exporting Company: ______________________________________________________________

Business Address: _________________________________________ Contact Number: ______________ Port of Loading: ______________________ Port Address: ______________________________________ Expected Date of Arrival: _________________________________________________________________ Expected Port of Arrival: _______________ Port Address: ______________________________________ VII. Present Inventory of Same Substance Subject for Importation (under applicants custody) Quantity (in kg): _____________________________ Size of Storage Area (in m 2): ___________________ VIII. Fees; ____________________OR # _________________________Date__________________

I acknowledge that this application form is a legally binding document, and I declare, under the penalties of perjury, that the same has been accomplished in good faith, verified by me, and, to the best of my knowledge and belief, is true and correct pursuant to the regulations issued under authority thereof. ___________________________________ (Authorized Signature over Printed Name)

FORM B
RECORD OF ACT UAL ARRIVAL OF SHIPM ENT (RAAS)
Important Note: This document provides information relevant to the immediately preceding importation for the same substance applied for and is a vital requirement for processing any subsequent import application. It must be fully accomplished and submitted with the appropriate Bill of Lading.

Enclosure / Attachment of Application Control Number: _____________

1. 2.

Company Name

: ___________________________________________________________________

Preceding Pre-Shipment Importation Clearance Information a. b. c. d. e. Application Control Number : ____________________________________________________

Brand / Trade / Commercial Name : ____________________________________________________ Issued Quantity (in kg) Date Issued Expiration Date : ____________________________________________________ : ____________________________________________________ : ____________________________________________________

3.

Actual Arrival of Import Bill of Lading (please mark X the box if Bill of Lading is attached) a. b. c. d. Date of Actual Arrival : _______________________Unit Cost / Net Weight (in kg): _______________ Actual Arrival Quantity / Net Weight (in kg) : _______________________________________

Bill of Lading No.: ___________________________ Bill of Lading Quantity: ____________________ Invoice No. of : ______________________________ Invoice No. Quantity: _____________________

4.

Port of Arrival and Address: ____________________________________________________________

5.

Substance Identity a. b. Single or Multiple Chemical Composition : _____________________________________________ For Single Chemical Composition Generic Name: ________________________________ Chemical Formula: _____________ c. For Multiple Chemical Composition Blend Generic Name: ______________

Percent: ______ Generic Name: ________________________________ Chemical Formula: _____________ Percent: ______ Generic Name: ________________________________ Chemical Formula: _____________ Percent: ______ Generic Name: ________________________________ Chemical Formula: _____________ Percent: ______ Generic Name: ________________________________ Chemical Formula: _____________ Percent: ______ Generic Name: ________________________________ Chemical Formula: _____________

AUTHORIZED SIGNATURE : ____________________________________________________________

NAME POSITION DATE : ____________________________________________________________ : ____________________________________________________________ : ____________________________________________________________

FORM C
SUMM ARY OF T RANSACT IONS FOR PREVIOUS INVENTORY AND IMM EDIAT ELY PRECEDING IMPORT AT ION OF THE SAM E SUBST ANCE
Important Note: This document describes how previous inventory and importation of the same substance applied for were Enclosure / Attachment of distributed to suppliers and end-users. This is crucial in cross-checking the previously declared actual Application Control Number transactions. All information must be supplied completely. Fill up as many forms as necessary. All

: _________________

BRAND / TRADE / COMMERCIAL NAME: _______________________________________________________ PRECEDING PRE-SHIPMENT IMPORTATION CLEARANCE APPLICATION CONTROL NUMBER: ________________________________________________ PREVIOUS INVENTORY QUANTITY (in kg)_______________________________________________ QUANTITY APPLIED (in kg) : ________________________________________________ ACTUAL ARRIVAL QUANTITY (in kg): ________________________________________________ TOTAL QUANTITY DISTRIBUTED (in kg) Name of Person or Company Contact Number : ______________________________________________ Nature of Enterpris Intended Use Quantity Official e (dealer (for endDistribute Receipt and/or user) d (in kg) Number end-user)

Address

Date of Sale

DATE ACCOMPLISHED: _____________________________________________________________________ SIGNATURE NAME POSITION : ______________________________________________________________________ : ______________________________________________________________________ : ______________________________________________________________________

TOTAL QUANTITY DISTRIBUTED (in kg)

: ________________________________________________ Nature of Enterpris e (dealer and/or end-user)

Name of Person or Company

Address

Contact Number

Intended Use (for enduser)

Quantity Distribute d (in kg)

Official Receipt Number

Date of Sale

DATE ACCOMPLISHED: _____________________________________________________________________ SIGNATURE NAME POSITION : ______________________________________________________________________ : ______________________________________________________________________ : ______________________________________________________________________

FORM D
LIST OF INT ENDED USERS FOR T HE PRE-SHIPMENT IM PORT AT ION CLEAR ANCE APPLICAT ION
Important Note: This document enumerates all persons, natural or juridical, to whom the substance to be imported will be distributed. The same will be validated by the transaction records to be appended on the succeeding applications.

Enclosure / Attachment of Application Control Number: _____________

BRAND / TRADE / COMMERCIAL NAME: _______________________________________________________ QUANTITY TO BE IMPORTED (in kg) : __________________________________

TOTAL QUANTITY INTENDED TO BE DISTRIBUTED (in kg) : __________________________________ Nature of Intended Name of Enterprise Intended Use Purchase Order Contact Quantity to be Address Person or (dealer Number Covered Number (for end-user) Distributed (in and/or Company by Transaction kg) end-user)

DATE ACCOMPLISHED: _____________________________________________________________________ SIGNATURE NAME POSITION : ______________________________________________________________________ : ______________________________________________________________________ : ______________________________________________________________________