Republic of the Philippines DEPARTMENT OF ENVIRONMENT & NATURAL RESOURCES ENVIRONMENTAL MANAGEMENT BUREAU-XII Region 12 Center, Brgy. Carpenter Hill, Koronadal City Tel. No. (083) 228-1071 / Fax No. (083) 228-1072 ______

APPLICATION FORM FOR PERMIT TO OPERATE AIR POLLUTION INSTALLATION

New Renewal Expiry Date Application No.

IMPORTANT: Read carefully the instruction before accomplishing this form. The applicant Pollution Control Officer or any other person responsible for the representing false statement/documents shall be prosecuted to the full extent of the law. Attach supporting documents

1. Name of Firm/Establishment : ______(Plant) : ______Tel. No: ______Address: ______2. Name of Pollution Control Officer: ______2.2 C.O.A. No.______Date Issued:______2.3 Tel. No:______Celphone No:______3. Location as to Land Use: Industrial ( ) Commercial ( ) Residential ( ) Agricultural ( ) 4. Area presently occupied: Company owned ( ) Leased ( ) Area ( ) If under lease, date of Expiration: ______5. Capital Investment (Authorized) : ______Paid Up: ______6. Type of Industry / General Nature of Business: ______7. Number of Employee (Office) ______Plant______8. Plant Operation (Hrs/Day)______(Days/Week)______(Shift/Day)______9. Type of Manufacturing Process(es): Continuous ( )______Batch ( )______Others ( )______10. Raw Material(s) capacity Product(s) Capacity: ______11. List of Air Pollution Source Equipment (APSE) Process (es) and corresponding Air Pollution Control Facility (ies) (APCF) covered by the permit application. (Use additional sheet if necessary)

Type of Air Pollution Source Equipment/Air Pollution Control Facility Date Constructed/Installed APSE APCF a. b. c. d.

CERTIFIED CORRECT:

______Printed name & Signature of PCO Printed Name and Signature of CEO

Permit Fee: ______O.R. No. ______Date Issued: ______Filing Fee: ______O.R. No. ______Date Issued: ______LRF: ______O.R. No. ______Date Issued: ______INSTRUCTIONS

1. Cover Letter (Letter of intent to apply for Permit to Operate Air New or Renewal); 2. FULLY ACCOMPLISH THE APPLICATION FORM, “HAVE IT NOTARIZED” and COMPLETE ALL THE SUPPORTING DOCUMENTS indicated hereunder. Present all documents in triplicate copies to Discharge and Permit-to-Operate Section (DPOS) for its pre-evaluation. (DPOS will issue Order of Payment (OP) after passing the pre-evaluation) 3. Pay the corresponding amount (indicated in the OP) to Cahier’s unit and photocopy the OP and the Official Receipt (OR) and insert/include it in your application and present it to DPOS Evaluator. 4. File your application to the Secretary from the Office of the Regional Director (ORD). 5. Your application will be acted upon within twenty-five (25) working days. If there are any lacking document(s) found in your application, a letter will be sent to your firm addressed to the Owner/General Manager/CEO to provide the needed document(s) so that your application will be processed. Note: Failure to submit the necessary requirements shall be sufficient ground for the disapproval of the application. NOTE: INCOMPLETE APPLICATION WILL NOT BE ACCEPTED TYPES OF APPLICATIONS DOCUMENTS REQUIRED New 1, 2, 3, 4, 5, 6, 8, 9, 10, 13, 14 Renewal 5, 6, 7, 8, 9, 11, 12,13, 14 1. An ENGINEERING REPORT that contains; - Plant description and operations, the estimated types, concentrations and quantities of all emissions to the atmosphere. - The control facilities, the emission rate and annual mass emission objectives; and, - The design criteria for air pollution control equipment, and other relevant information.

*The design criteria, if warranted, shall be based on the results of laboratory and pilot plant scale studies. The design efficiencies of the air pollution control equipment and the quantities and types of pollutants in the final emissions shall be indicated. 2. The PLANS AND SPECIFICATIONS of the installation and its control facilities (preferably in standard size of (50 cm by 90 cm) duly certified by a registered professional mechanical engineer, mechanical engineer, chemical engineer or any appropriate engineer or a combination of any of two or all of them as maybe required by the Bureau depending upon the nature of the construction, operation or activity sought to be covered by the Permit. (The plans shall clearly show is adequate detail the arrangement, location and size of the pollution control equipment or facilities including their accessories, cross-sections and construction details. The specifications shall be in sufficient detail so that, when read in conjunction with the plans, they clearly reveal the proposed means and methods for the control of pollution and their expected performance efficiency.) 3. The project proponent shall CONDUCT AN AIR QUALITY IMPACT ANALYSIS using Bureau- approved computer dispersion models and techniques. The impact analysis shall estimate the resulting ambient air concentrations for all significant pollutants from the facility, and shall include the existing ambient air concentrations as a baseline. (The impact analysis will be used by the Bureau, together with other relevant information, to determine if the construction or modification will result in a violation of an applicable air quality standard). 4. A VICINITY MAP adequately identifying the street address, if any, of the location or premises of the installation.

5. A STATEMENT OF COMPLIANCE OR NON-COMPLIANCE WITH RULE XXV (Pollution from Stationary Sources or, in the case of incinerators, a statement of compliance or non-compliance with Rule XXVIII). The statement of compliance shall be supported with actual test data (such as stack sampling test data), or gathering techniques acceptable to the Bureau. 6. A STATEMENT OF COMPLIANCE OR NON-COMPLIANCE WITH RULE XXVI AMBIENT AIR QUALITY STANDARDS. The statement of compliance shall be supported by the dispersion modeling data using the modeling techniques and sampling approved by the Bureau. 7. A COMPLIANCE ACTION PLAN FOR SOURCES not meeting regulatory requirements. The Compliance Plan may include provision for use of emission averaging and/or trading as allowed under Parts III and IV.

8. A CERTIFICATION SIGNED BY THE APPLICANT attesting to the accuracy and completeness the application.

9. A COPY OF THE CERTIFICATE OF ACCREDITATION OF THE POLLUTION CONTROL OFFICER (PCO) duly issued by the Department; or a signed copy of the appointment or designation of Pollution Control Officer (PCO) together with his/her biodata.

10. COPY OF ENVIRONMENTAL COMPLIANCE CERTIFICATE (ECC) OR CERTIFICATE OF NON- COVERAGE (CNC) issued from the Bureau, as applicable.

11. PHOTOCOPY OF THE LATEST PERMIT TO OPERATE .

12. PHOTOCOPY OF THE LATEST SUBMITTED SELF MONITORING REPORT (SMR) 13. PHOTOGRAPHS OF APSE/APCF.

14. OTHER INFORMATION AND DATA AS MAY BE NEEDED BY THE BUREAU.