Republic of the PhilippinesDEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCESENVIRONMENTAL MANAGEMENT BUREAU-Region VI2nd Flr. Pacita Salazar Bldg, EL 98 St., Jaro, Iloilo CityTel. No.: 3001135 * Telefax: (033)5099133 * Email: embr6@yahoo.com

APPLICATION FOR PERMIT TO OPERATE(Air Pollution Source and Control Installations)

Type: ( ) New ( ) Renewal ( ) Extension

( ) Change of Ownership ( ) Change of Name ( ) Modification

1. General Information:Name of Enterprise: _________________________________________________________________Address: __________________________________________________________________________Name of Establishment: ______________________________________________________________Address: __________________________________________________________________________TIN: ____________ Nature of Business: _________________________________________________Nature of Ownership: ( ) Single Proprietorship ( ) Partnership ( ) CorporationAuthorized Capital: ________ Paid Up Capital: ____________ Date of Start of Operation __________Name f CEO: _____________________ Tel No. _________________ Fax No. ___________________Total Employees: _____________ Office: _______________ Production: _______________________Office Operation: ____ hrs/day _____ days/wk Production Operation _______ hrs/day ____day/wkLand Area Occupied: _____sq.m Open Area: ______ sq.m. ( ) Owned ( ) Leased ( ) SharedClassification: ( ) Industrial ( ) Commercial ( ) Residential ( ) Agricultural ( ) ________________

2. Raw Materials & Product Information ( ) Not Applicable

Raw MaterialsQuantityProductsQuality

3. List of Air Pollution Source Installation (APSI)APSIControl Facility

I hereby certify that the above information are true and correct to the best of my knowledge. Done this __________ day of _________________ 20_______.

______________________________________ __________________________Name and Signature of Pollution Control Officer Chief Executive Officer

SUBSCRIBED and SWORN to before a Notary Public. This _____ day of _______ affiant exhibiting to me his/her Community Tax Receipt No. ________________ issued at ______________ issued on ________________

NOTARY PUBLIC

Filing Fee: _________________ Official Receipt No. _______________ Date _______________Permit Fee: ________________ Official Receipt No. _______________ Date _______________P.D. 1856 _________________ Official Receipt No. _______________ Date _______________

Application No. _______Assessed by: ________________________________

INSTRUCTIONS

1. Fully accomplish this form and complete all the supporting documents indicated hereunder. Submit all documents in triplicate copies to our Air Quality Management Section of the Pollution Control Division for screening, assessment of fees, and issuance of Order of Payment.

2. Pay to the Cashier Section the corresponding amount indicated in the Order of Payment and present the Official receipt to Air Quality Management Section for recording and notation of your application.

3. Submit your application to the Records Unit and ask for your receiving copy.

Your application shall be acted upon within twenty five (25) working days and you shall be informed of our action accordingly.

Types of ApplicationDocuments Required

NewItem Nos. 1, 2, 3, 4, & 5

Additional/ModificationItem Nos. 1, 2, 3, 4, & 5

Change of Name/OwnershipItem Nos. 4, 6, 7, & 5

RenewalItem Nos. 6 & 9

Supporting Documents

1. Engineers Report with at le4ast containing the following: Description of process including the amount of raw materials & finished products, all emissions into the atmosphere and or the material balance; List of APSI and corresponding Air Pollution Control Facility (APCF) with complete specifications; Discussion of APSI & APCF showing the process/mode of operation, design criteria & efficiencies of the APCF, the quantities & types of pollutants in the final emissions. Pollution loading of the regulated air pollutants in tons/year.

2. Drawing requirements in 50cm x 90cm paper signed by the President/General Manager and duly signed and sealed by PME/ChE. Or any appropriate engineer. Vicinity Map; Plant & Machinery Layout showing the connection of the APSI to APCF; Plan & Elevation drawings of each APSI & APCF.

3. Copy of the Certificate of Accreditation of the Pollution Control Officer (PCO), or appointment/designation as such by the Managing Head;

4. Environmental Compliance Certificate (ECC) or Certificate of Non-Coverage (CNC) copy.

5. Source Emission Test Requirement (if required).

6. Copy of the recent Permit to Operate issued by the Office.

7. Copy of SEC Registration Certificate & Articles of Incorporation.

8. Copy of DTI Registration Certificate.

9. Proof of compliance to permit conditions (if required)