Self - Monitoring Report

LLDA report form for monitoring

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QUARTERLY SELF-MONITORING REPORT
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Quarter Months Covered : __________________________

A. General Information
Name of the Plant
Plant Address

Street No. & Street Name _______________________________________

(NOT the company or

Barangay __________________ City or Municipality___________________

the head office)

Province

___________________________________________________

Phone Number

Fax Number

Type of Business

TIN Number

Name of the PCO
Single Proprietorship

Partnership

Govt. Corporation

Multi-national

Ownership in Terms of
Equity Participation

Private Domestic _____%

Foreign _____%

Market Where Goods
are Sold

Domestic _______%

Private Domestic Corporation

Legal Classification
Other

Specify ___________

Government _____%

Export _______%

Is the Establishment Traded in the Stock Market?

Yes

No

If Yes, Under What Name: ___________________________________________

If the head office is not located at the above address, please fill-up
Name of the Company
Street No. & Street Name ______________________________________
Address

Barangay _________________ City of Municipality _________________
Province ____________________________________

Phone Number _______________________________

Fax Number _________________________

Note:
Please observe the required frequency of analysis and submission of SMR
Flowrate
Type
Frequency
0-150 m3/d
BOD,conventional parameters
Once every quarter
0-150 m3/d
Hazardous waste
Once every month
> 150 m3/d
BOD, conventional parameters
Once every month

Submission of SMR
Semi-Annualy
Quarterly
Quarterly

LLDA-CPD-Form 17

Issue No.: 01

Issue Date: April 2015

Pg 1 of 8

B. Wastewater Treatment Plant (WTP) Record
B.1 Average Duration of Time Operated & Ave. Volume of Discharge Per Day
Month 1 ___________, 200_

Day of the
Month

Hours of
Operation

Effluent Flow Rate
3
m /day

Month 2 ___________, 200_
Hours of
Operation

Effluent Flow
3
Rate m /day

Month 3 ___________, 200_
Hours of
Operation

Effluent Flow Rate
3
m /day

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2
3
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5
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7
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10
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31
Ave./Mo.
Were there any major interruptions in WTP operation? For example, due to equipment breakdown or major maintenance
procedures. Yes
No
. If yes, please attach explanation on separate page.
LLDA-CPD-Form 17

Issue Date: April 2015

Issue No.: 01

Pg 2 of 8

B.2 Record of the Cost of Treatment
Operating Cost of the Wastewater Treatment Plant
Month 1________________
New or Additional
Investment

Month 2________________

Name of the
Component

Name of the
Component

Cost (pesos)

Cost (pesos)

Month 3________________
Name of the
Component

Cost (pesos)

kwH

Cost (pesos)

in the WTP
kwH

Cost (pesos)

kwH

Cost (pesos)

Energy Usage of the
WTP
Persons Employed
Full-time for the

Total

Avg. Hrs.

Total Cost

Total

Avg. Hrs.

Total Cost

Total

Avg. Hrs.

Total Cost

Number per Day

(pesos)

Number per Day

(pesos)

Number per Day

(pesos)

Total Avg. Hrs.
Number per Day

Total Cost
(pesos)

Total Avg. Hrs.
Number per Day

Total Cost
(pesos)

Total Avg. Hrs.
Number per Day

Total Cost
(pesos)

WTP
Persons Employed
Part-time for the
WTP
Cost of Chemicals
Used by WTP (pesos)
Total Maintenance
Cost-repairs, spare
parts etc. (pesos)
Administrative and
Overhead Cost (pesos)

Laboratory Cost
Is there a laboratory in the factory premises? Yes
Month 1________________

No
Month 2________________

Month 3________________

If Yes, monthly cost
of operating the
laboratory (pesos)

LLDA-CPD-Form 17

Issue Date: April 2015

Issue No. : 01

Pg 3 of 8

C.1 Monthly Report of Wastewater Characteristics for Conventional Pollutants
Description of the Outlet:

X-UTM ____________________________

Is this the only outlet for the wastewater:

Yes

No

Y-UTM ____________________________

If No, please submit this report for other outlets also

Make a copy of this table if needed. For zero discharge scheme, you may not fill-up this page.
BOD
Date

COD

TSS

Color

Temperature

pH

Oil & Grease

Coliform

(mg/l)

(mg/l)

(mg/l)

.

(oC)

.

(mg/l)

MPN/100ml)

Influent

Effluent

Influent

Effluent

Influent

Effluent

Influent

Effluent

Influent

Effluent

Influent

Effluent

Influent

Effluent

Influent

Ave./Mo.

Please attach Results of Laboratory Analysis (ROLA)
Name of the Laboratory
Address

LLDA-CPD-Form 17

Phone

Issue Date: April 2015

Issue No.: 01

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Effluent

C.2 Monthly Report of Wastewater Characteristics for Other Pollutants
Description of the Outlet: X-UTM ________________________
Is this the only outlet for the wastewater:

Yes

No

Y-UTM _______________________
If No, please submit this report for other outlets also

Make a copy of this table if needed. For zero discharge scheme, you may not fill-up this page.
Effluent
Parameter Name
Flow Rate in
______________
terms of
Date

of: Cubic

Unit _________

Parameter Name

Parameter Name Parameter Name Parameter Name

Parameter Name Parameter Name

______________

______________

______________ ______________

______________

______________

Unit _________

Unit _________

Unit _________

Unit _________

Unit _________

Unit _________

meters/day Influent Effluent Influent Effluent Influent Effluent Influent Effluent Influent Effluent Influent Effluent Influent Effluent

Please attach Results of Laboratory Analysis (ROLA)
Name of the Laboratory
Address

Phone

Pg 5 of 8

LLDA-CPD-Form 17

Issue Date: April 2015

Issue No.: 01

Pg 5 of 8

D.

Background Data

D.1 Sources of Wastewater during this Quarter
Estimated Flow (m3/day)

Generating Process
Production Process
Washing/Cleaning
Cooling
Domestic Wastewater
Recyled/Reuse Water/Others
Total Volume of Discharged Wastewater

D.2 Employment and Operation Information
Total employment in the factory:

Production

Non-Production ________

Number of hours of production/day __ Number of days of production per/month __
Number of months of production/year _____
Total value of investment in the factory: (Pesos)____________________
Average Energy Consumption:
(please check monthly or annual)

Coal (tons)
Electricity (kwh)
Gas (m3)
Oil (m3)
Monthly or Annual Monthly or Annual Monthly or Annual Monthly or Annual

Quantity
Value (Pesos)
D.3 Production Information - See Attached
Product 1

Product 2

Product 3

Product 4

Product 5

Product Name1
Max. Allowable
Production Capacity
per Year
Actual Average
Production per
Month
Type of
Process

1

Batch

Batch

Batch

Batch

Batch

Continuous

Continuous

Continuous

Continuous

Continuous

Please use generic product name; not brand names.

LLDA-CPD-Form 17

Issue Date: April 2015

Issue No.: 01
Pg 6 of 8

D.4 Water Pollution Information
INFORMATION ON DISCHARGE POINTS IN THE FACTORY
Outlet

Location & Description

Name of the Receiving Body if Not

Number

of the Outlet

Discharging Directly in the Lake

1

2

3

4
INFORMATION ON THE WASTE WATER TREATMENT SYSTEM
Is there an existing waste water treatment system?

Yes

If yes, what is the capacity of the waste water treatment system?

________cubic meter

Value of capital investment in the waste water treatment plant

Pesos_______________

Yes

Is there a primary treatment system?

No

Year Installation

No

Month_______Year____

If Yes, what is the composition of the physical treatment system?
Screening

Equalization

Sedimentation

Grit Removal

Oil-water separator

If other, specify______________________________________

Is there a chemical treatment process?

Yes

Year of Installation

No

Month ______________Year________

If Yes, what is the composition of the chemical treatment system?
Adsorption

Disinfection

Flocculation/Coagulation

pH Adjustment

If other, specify _______________________________________________________
Is there a secondary treatment system?

Yes

Year of Installation

No

Month ______________Year________

If Yes, what kind of secondary treatment system is installed in the plant?
Activated Sludge

Anaerobic & Aerobic Treatment

Oxidation/Stabilization Pond

Anaerobic Treatment

Rotating Biological Contactors

Trickling Filter

Others, Specify : _______________

LLDA-CPD-Form 17

Issue Date: April 2015

Issue No.: 01

Pg 7 of 8

D.5 FLOW METER INFORMATION
Is there a flow meter to measure the quantity of waste water

Yes

No

discharged from the plant?
What type of flow meter is used for measuring the wastewater discharge rate?
Rectangular Weir

Triangular Weir

Other Weirs

Venturi Meters

Magnetic flow Meters

Current Meters

Flow Measurements

If other, please specify__________________________________
_______________________________________________________________________________

D.6 MANAGEMENT OF SLUDGE FROM WASTE WATER TREATMENT SYSTEM - N/A
Is the quantity of sludge large enough to require proper management?

Yes

No

Which method is used for removing water from the sludge?
Drying Beds

Vacuum Filtration

Pressure Filtration

Centrifugation

If other, specify ___________________________________________________________________
How is the sludge dried?

Heat Drying

Incineration

Wet Oxidation

If other, specify ___________________________________________________________________
How is the sludge disposed of?
Landfill inside the
Landfill outside
factory
the factory

Ocean dumping

If other, specify ___________________________________________________________________

Submitted on Date ______________

Name and Signature of the Pollution Control Officer

Name and Signature of the Chief Executive Officer

SUBSCRIBED AND SWORN to before me a Notary Public, This_____day of ___________________,
affiant exhibiting to me his/her Community Tax Receipt No.__________, issued at_________ on _______.

NOTARY PUBLIC

LLDA-CPD-Form 17

Issue Date: April 2015

Issue No. :01

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