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Apsce Forms

This document is an application for a permit to operate air pollution sources and control installations from the Department of Environment and Natural Resources in the Philippines. It requests information from applicants such as the name and address of the firm, the types and details of air pollution equipment, maintenance plans for pollution control equipment, and confirmation that required supporting documents are submitted. The instructions explain that applicants must fully complete the form and submit it along with documents like an engineer's report on pollution sources and controls, a vicinity map, documents appointing a pollution control officer, and zoning and non-coverage certificates.

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74 views2 pages

Apsce Forms

This document is an application for a permit to operate air pollution sources and control installations from the Department of Environment and Natural Resources in the Philippines. It requests information from applicants such as the name and address of the firm, the types and details of air pollution equipment, maintenance plans for pollution control equipment, and confirmation that required supporting documents are submitted. The instructions explain that applicants must fully complete the form and submit it along with documents like an engineer's report on pollution sources and controls, a vicinity map, documents appointing a pollution control officer, and zoning and non-coverage certificates.

Uploaded by

Neil Ryan
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOC, PDF, TXT or read online on Scribd
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Republic of the Philippines

Department of Environment and Natural Resources


ENVIRONMENTAL MANAGEMENT BUREAU
Regional Office V
Legazpi City

APPLICATION FOR PERMIT TO OPERATE


For Air Pollution Source and Control Installations
(IMPORTANT: Read the INSTRUCTIONS at the back before accomplishing the form)
TYPE: New Renewal Change of Ownership
1. Name and Position of Applicant :

2. Name of Firm/Establishment :

3. Office Address : Tel No. :

4. Plant Location : Tel No. :

5. Capitalization Authorized : Paid Up :

6. Name of Accredited Pollution Control Officer : Tel No. :

7. Nature of Business :

8. List of Air Pollution Source Equipment (APSE) Process(es) and corresponding Air Pollution Control
Facility(ies) (APCF) covered by the permit.

Description Date Installed

(e.g 500 Hp boiler/scrubber, 10-ton capacity


reverbetory bag house) APSE APCF
a.
b.
c.

9. Maintenance and Operating of APCEs: a. Power :


b. Labor :
c. Replacement Parts :
d. Others (Specify) :

10. For new permit application, total cost of all APCEs (including construction cost) covered by the
same :

11. Have you submitted all thee required SUPPORTING DOCUMENTS listed at the back?
[ ] Yes [ ] Partially [ ] No

If YES, submit only this application form duly accomplished and indicate in the transmittal letter
that no modification(s) had been made previously submitted documents.

If PARTIALLY or NO, submit all lacking documents respectively. Indicate the partially
submitted in the transmittal letter. (Refer to Item No. 2 of INSTRUCTION at the back).

CERTIFIED CORRECT:

___________________________________________
Signature Over Printed Name
Filing Fee O. R. No. Date
Permit Fee O. R. No. Date
PD 1856 O. R. No. Date
PAB Res 10A O. R. No. Date
INSTRUCTION FOR FILING APPLICATION

1. This form shall be fully accomplished and the required supporting documents shall be
submitted completely, otherwise the application will be returned.
2. This form and the required supporting documents shall be submitted in duplicate
copies of applicant if the plant/establishment is located in Luzon and in triplicate
copies if located in Visayas and Mindanao and shall be accompanied by a letter of
transmittal addressed to the Regional Director, EMB V.

SUPPORTING DOCUMENTS

1. Engineers Report covering the following:


a. List of Air Pollution Source Equipments (APSE) and its corresponding control
devices (APCF) [including its capacity and usage];
b. Specific Fuel Consumption per hour or per month (Liters) for generator sets
and boilers; Raw materials capacity (ricemills)
c. Process Flow Diagram of APSE and APCF (including raw materials input and
output);
d. Pictures of Air Pollution Source and Control Equipments
e. Environmental Management Plan; and
f. Plant/Machinery Lay-out;

2. Vicinity Map

3. A signed copy of the appointment/designation of the Pollution Control Officer (PCO)


of the applicant together with the following:
a. Application letter for PCO Accreditation;
b. Updated Bio-Data of appointed PCO;
c. Appointment/ Designation Letter of Pollution Control Officer (PCO) from the
company
d. Copy of certificates of relevant trainings/seminars attended.

4. Zoning Certification

5. Certificate of Non-Coverage

SUBSCRIBED AND SWORN to me before a Notary Public. This ___ day of __________ , affiant exhibiting to me his/her Community Tax
Receipt No. ______________ issued at _________________________ on _______________________ .

NOTARY PUBLIC

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