Self-Monitoring Report (SMR) System
For _____________ Quarter of CY _________________
Name of Company: __________________________________________________
Address:___________________________________________________________
Environmental Management Bureau
DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCES
QUARTER ______ YEAR _______
Module 1: General Information page ____ of ____
GENERAL INFORMATION SHEET
Name of the
Establishment/Facility
Establishment/Facility Street # & Street Name: ____________________________________
Address Barangay: ___ City/Municipality: ____________________
(NOT the company of head
office) Province:
Name of
Owner/Company
Street # & Street Name: _________________________
Address
(if address is not the same Barangay: City/Municipality: __
as previous address)
Province:
Phone Number Fax Number
e-mail address
Type of Business/ Philippine Standard Industry Classification Code No. _____
Industry
Classification Philippine Standard Industry Descriptor: ______
CEO/President. ____
Tel #: _________ Fax #: _______________
Responsible e-mail address:
Officer/s: Plant Manager: ______
Tel #: ___________ Fax #: ______________
e-mail address: _______
Name. _______ ____
Pollution Control
Officer Tel #: Fax #: __________
e-mail address: __________
single proprietorship partnership
Legal Classification private domestic corporation government corporation
Multi-national
We hereby certify that the above information are true and correct.
_______________________________ __________________________
Name/Signature of CEO/President Name/Signature of PCO
QUARTER ______ YEAR _______
Module 1: General Information page ____ of ____
Department of Environment and Natural Resources
Environmental Management Bureau
Period covered_______________________
MODULE 1: GENERAL INFORMATION
Name of the Plant
Please provide the necessary revised, corrected or updated information not contained in your
General Information Sheet
(use additional sheet/s if necessary)
DENR Permits/Licenses/Clearances
Environmental
Permits Date of Issue Expiry Date
Laws
RA 9275 PO No.
CNC
PD 1586 ECC 2
ECC 3
DENR
Registry ID
CCO Registry
RA 6969 Importer
Clearance No
Permit to
Transport
RA 8749 PO No.
QUARTER ______ YEAR _______
Module 1: General Information page ____ of ____
Operation
Operating hours/day Operating days/week # of shift/day
Average
Maximum
Operation/Production/Capacity:
Average Daily Total Output this
Production Output Quarter
Total Water Total Electric
Consumption this Consumption this
Quarter (cubic meters) Quarter (KwH)
Please use additional sheet/s if necessary
For All Establishments
Total Raw Materials Processed this Quarter
(tons)
Total Production Output this Quarter (tons)
For Gasoline Refilling Stations
Total Gasoline Delivered for this Quarter
Total Gasoline Dispensed for this Quarter
QUARTER ______ YEAR _______
Module 1: General Information page ____ of ____
MODULE 2: RA 6969
A. CCO Report (please accomplish this section for each chemical/substance)
Common Name/IUPAC/CAS Index Name.
CAS No.: ___
Trade Name: ___
For importers only:
Import
Quantity Date of Quantity Port of Country of Country of
Clearance
Requested Arrival Received* Entry Origin Manufacture
No.
Total Quantity Total Quantity
Requested (annual) Received (annual)
* attach copy/s of Bill of Lading
For distributors (importers/non-importers)
Name of Client License No. Quantity Date of Distribution
Total Quantity Distributed
For non-importer users:
Name of Distributor Quantity Date of Purchase
Total Quantity Purchased from Distributor
For producers
Average Daily Total Output this
Production Output Quarter
Quantity of Stock Quantity of Stock
Inventory (Start of Inventory (End of
Quarter) Quarter)
Name of Buyer Quantity Date of Purchase
Module 2A: RA 6969 (CCO Report) page ____ of ____
Total Quantity Sold
Used in Production (please fill up only if chemical/substance is not main product)
Average Daily Total Output this
Production Output Quarter
Average Quantity Used Total Quantity Used
per month this Quarter
Describe any changes in Production/Process/Operations:
Stock Inventory/Waste Chemical Generated:
Average Quantity of Total Quantity of Waste
Waste Chemical Chemical Generated
Generated per month this Quarter
Quantity of Stock Quantity of Stock
Inventory (Start of Inventory (End of
Quarter) Quarter)
Other Information:
Manner of handling storage on-site Treatment on-site
hazardous wastes storage off-site Treatment off-site
Changes in Safety Yes (please attach copy of revised plan)
Management System No
Chemical Substitute Yes (please attach copy if not submitted/included in previous report/s or had been revised)
Plan No
Module 2A: RA 6969 (CCO Report) page ____ of ____
B. Hazardous Wastes Generator
HW Generation:
HW Remaining HW from
HW Generated
HW No. HW Class HW Nature Cataloguin Previous Report
g Quantity Unit Quantity Unit
Waste Storage, Treatment and Disposal:(Please fill-up one table per HW)
HW No,: ___
HW Details Qty of HW Treated: Unit: ___
TSD Location: ___
Name: ___
Storage
Method: ___
ID: Name: ___
Transporter
Date: ___
ID: Name: ___
Treater
Method: Date: ___
ID: Name: ___
Disposal
Method: Date: ___
HW No,: ___
HW Details Qty of HW Treated: Unit: ___
TSD Location: ___
Name: ___
Storage
Method: ___
ID: Name: ___
Transporter
Date: ___
ID: Name: ___
Treater
Method: Date: ___
ID: Name: ___
Disposal
Date: Date: ___
Module 2B: RA 6969 (Hazardous Wastes Generator) page ____ of ____
On-Site Self Inspection of Storage Area:
Premises/Area Findings & Corrective Action
Date Conducted
Inspected Observations Taken (if any)
Module 2B: RA 6969 (Hazardous Wastes Generator) page ____ of ____
C. Hazardous Wastes Treater/Recycler
HW Stored and/or Untreated as of End of Quarter:
Type of
Transport Storage Time Table
HW Wastes Date of
Permit/Date Valid until Quantity Container/ for
Number Generator Transport
of Issue # of Treatment
containers
HW Treated and/or Recycled as of End of Quarter:
Type of Type &
Transport Treatment Quantity of
Type of HW Wastes Date of
Permit/Date Quantity or Recycled
Wastes Number Generator Transport
of Issue Recycling or Treated
Process Product
Residual Wastes Generated from the Treatment and/or Recycling Operation:
Type of
Process by
Storage
Type of which the Disposal Time Table
HW Number Quantity Container/
Wastes Wastes is Option for Disposal
# of
Generated
containers
Module 2C: RA 6969 (Hazardous Wastes Treater/Recycler) page ____ of ____
MODULE 3: RA 9275 (Water Pollution)
Water Pollution Data
Domestic wastewater Process wastewater
(cubic meters/day) (cubic meters/day)
Cooling water Others: ___________
(cubic meters/day) (cubic meters/day)
Wash water, Wash water, floor
equipment (m3/day) (cubic meters/day)
Record of Cost of Treatment (Separate entries for separate facilities)
Month 1 Month 2 Month 3
Person employed, (# of
employees)
Person employed,
(cost)
Cost of Chemicals
used by WTP
Utility Costs of WTP
(electricity & water)
Administrative and
Overhead Costs
Cost of operating in-
house laboratory
New/Additional
Investments in WTP
(Description)
Cost of New/Add
Investments
WTP Discharge Location
Outlet
Location of the Outlet Name of Receiving Water Body
Number
1
2
3
4
5
Module 3: P.D. 984 (Water Pollution) page ____ of ____
Detailed Report of Wastewater Characteristics for Conventional Pollutants
Outlet No.
Effluent Oil & ________
BOD TSS Temp rise (name)
DATE Flow Rate Color pH Grease
(mg/L) (mg/L) (ºC)
(m3/day) (mg/L)
(unit)
Please fill-up/accomplish separate form/s for other outlet/s.
Detailed Report of Wastewater Characteristics for Other Pollutants
Module 3: P.D. 984 (Water Pollution) page ____ of ____
Outlet No.
Effluent ________ ________ ________ ________ ________ ________ ________
(name) (name) (name) (name) (name) (name) (name)
DATE Flow Rate
(m3/day)
(unit) (unit) (unit) (unit) (unit) (unit) (unit)
Please fill-up/accomplish separate form/s for other outlet/s.
Please use additional sheet/s if necessary.
Module 3: P.D. 984 (Water Pollution) page ____ of ____
MODULE 4: R.A. 8749 (Air Pollution)
Summary of APSE/APCF
Process Equipment Location # of hrs of operations
Fuel Burning Quantity # of hrs of
Location Fuel Used
Equipment Consumed operations
# of hrs of
Pollution Control Facility Location
operations
Cost of Treatment
Month 1 Month 2 Month 3
Cost of Person
employed, (salary)
Total Consumption of
Water (cubic meters)
Total Cost of chemicals
used (e.g., activated
carbon, KMnO4)
Total Consumption of
Electricity (KwH)
Administrative and
Overhead Costs
Cost of operating in-
house laboratory, if any
Improvement or
modification, if any.
(Description)
Cost of improvement of
modification
Module 4: RA 8749 (Air Pollution) page ____ of ____
Detailed Report of Air Emission Characteristics
Description/Location
of PCF
_______ _______
________ ________
Flow Rate CO NOx Particulates (name) _ _ (name)
DATE (name) (name)
(Ncm/day) (mg/Ncm) (mg/Ncm) (mg/Ncm)
(mg/Ncm) (mg/Ncm)
(mg/Ncm) (mg/Ncm)
Please fill-up/accomplish separate form/s for other PCF/s.
Please use additional sheet/s if necessary.
Module 4: RA 8749 (Air Pollution) page ____ of ____
MODULE 5: P.D. 1586
Ambient Air Quality Monitoring (if required as part of ECC conditions)
Description/Location
of Monitoring Station
_______ _______
________ ________
Noise CO NOx Particulates (name) _ _ (name)
DATE (name) (name)
Level (dB) (mg/Ncm) (mg/Ncm) (mg/Ncm)
(mg/Ncm) (mg/Ncm)
(mg/Ncm) (mg/Ncm)
(Please accomplish one table per monitoring station.)
Ambient Water Quality Monitoring (if required as part of ECC conditions)
Description/Location
of Sampling Station
________ ________ ________ ________ ________ ________ ________ ________
(name) (name) (name) (name) (name) (name) (name) (name)
DATE
(unit) (unit) (unit) (unit) (unit) (unit) (unit) (unit)
(Please accomplish one table per sampling station.)
Module 5: P.D. 1586 (EIS System) page ____ of ____
Other ECC Conditions
Status of Compliance
ECC Condition/s Actions Taken
Yes No
1.
2.
3.
4.
5.
6.
7.
Please use additional sheet/s if necessary.
Environmental Management Plan/Program
Status of
Enhancement/Mitigation Measures Implementation Actions Taken
Yes No
1.
2.
3.
4.
5.
6.
7.
Please use additional sheet/s if necessary.
Solid Waste Characterization/Information:
Average Quantity of Total Quantity of Solid
Solid Wastes Wastes Generated this
Generated per month Quarter
Average Quantity of Total Quantity of Solid
Solid Wastes Collected Wastes Collected this
per month Quarter
Entity in charge of
collecting solid wastes
Brief Description of
Solid Waste
Management Plan
(e.g., waste reduction,
segregation, recycling)
Module 5: P.D. 1586 (EIS System) page ____ of ____
Procedural and Reference Manual for DAO 2003-27
MODULE 6: OTHERS
Accidents & Emergency Records
Findings and
Date Area/Location Actions Taken Remarks
Observation
Personnel/Staff Training
# of Personnel
Date Conducted Course/Training Description
Trained
I hereby certify that the above information are true and correct.
Done this _________________________, in ________________________.
__________________
Name/Signature of PCO
_______________
Name/Signature of CEO
SUBSCRIBED AND SWORN before me, a Notary Public, this ________ day of
______________________, affiants exhibiting to me their Community Tax Receipts:
Name CTR No. Issued at Issued on
___________ ________________________________________________
___________________________________________________________________
Preparation and Submission of SMR 17
