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Application Form

LLDA application form for discharge permit

Your Browser Doesn't Support Canvas. Showing the Text Content of the PDF Instead: LAGUNA LAKE DEVELOPMENT AUTHORITY
National Ecology Center, East Avenue
Diliman, Quezon City
Tel. Nos.: 332-2346, 376-4039, 376-4072, 376-4049, 376-4061

APPLICATION FOR DISCHARGE PERMIT
NEW

RENEWAL

REVALIDATION Expiry Date of latest DP: __________ LLDA Establishment ID _________

A. APPLICANT INFORMATION
Name of Establishment/Project:_______________________________________________________________
Tax Identification Number (TIN): ________________________ Year Established: _________________________
Location of Establishment/Project:
Number and Street: _______________________________ Barangay: ________________________________
City/Municipality: _________________________________ Province: _________________________________
Tel. # :______________________________________ Fax #: _______________________________________
Business Activity: __________________________________________________________________________
Applicant’s Pollution Control Officer:
Name:
____________________________________Cert. of Accreditation No.:_______________________
Cel. #: ________________________________email add: __________________________________________
B. Employment and Operation Information
Total number of workers
Production: ________________
Non-Production: ____________

Operational Schedule/Time
No. of hours/day: ______ No. days/month: ________________
No. of days with discharge/month: _______________________

C. Project and Product Information
Total Floor Area (m2) __________________ Total Lot Area (m2) __________________________________
For Agro-Industrial Establishments
Registered No. of Heads (based on LLDA Clearance) _____________ Actual No. of Heads _____________
Product 1

Product 2

Product 3

Product 4

Product Name*
Annual Production Capacity
Previous year’s actual production
D. Water Sources, Consumption and Wastewater Generation
Box C: Wastewater Generation (m3/day)
3

Box A: Sources (m /day)
MWSI, MWCI

Box B:
Consumption (m3/day)

Recycled/
Re-used

Lost by
Evaporation

Contained in
Lagoon, Ponds,
Septic Tanks

Treated by
Service
Provider

Effluent
Discharge to the
Environment

Process Wastewater

Local Water District

Washing (cleaning of
equipment/kitchen wastes
from restaurants)

Deepwell

Domestic Wastewater

Surface Water (lake,
river, creek, etc.)

Cooling (make-up water)

Others (specify)

Others (drinking water,
gardening, product
component, etc.)

Total Water
Supply

Total Water
Consumption

Total Wastewater Discharge

NOTE: Box A and Box B must be equal (total water consumption)

E. Water Pollution Information
Location& Description
of the Outlet

Name of the
Receiving Body of
water

Estimated BOD
conc. (mg/l)

Estimated Ave. Rate of
Discharge (m3/day)

Mode of
Discharge

Schedule of Discharge
(Date and Time)

TOTAL
(continuation at the back)

LLDA-CPD-Form 11

Issue Date: December 2017

Issue No.: 03

F. Wastewater Treatment System Information
Septic Tank/s ( ) Wastewater Treatment Facility ( )
3

Capacity _________ (m /day)

Sewage Treatment Plant ( )

Others: ____________ None ( )

Total Capital Investment in treatment system: PhP____________

Is there a physical treatment?
Yes ( ) No ( )
Date Installed: ___________________
Screening ( ) Equalization ( )
Grit Removal ( ) Oil-Water Separator ( )
Sedimentation ( )
If others, specify _______________________
Is there a chemical treatment?
Yes ( ) No ( )
Date Installed: ___________________
Adsorption ( )
Disinfection/Chlorination ( )
Flocculation/Coagulation ( )
pH Adjustment ( )
If others, specify _______________________
Is there a biological treatment?
Yes ( )
No ( )
Date Installed: ________________
Activated Sludge ( )
Single Batch Reactor ( )
Anaerobic Digester/s ( )
Trickling Filters ( )
Oxidation/Stabilization Pond ( )
Lagoons ( )
Rotating Biological Contactor/s ( )
If others, specify _______________________
Is there a tertiary treatment system? Yes ( )
No ( )
Date Installed: ________________
Reverse Osmosis ( ) Microfiltration ( ) Ultrafiltration ( ) Nutrient Removal ( )
If others, specify ___________________
G. Flow Meter Information
Is flow meter installed?

Yes ( )

No ( )

Type (specify):________________________________

H. Sludge Management
Quantity of sludge _______________(m3/day)
Method of water removal from sludge
Drying Bed/s ( ) Vacuum Filtration ( ) Pressure Filtration ( ) Centrifugation ( ) If others, specify _______________
Method of Disposal
Landfill inside the factory ( ) Landfill outside the factory ( ) Ocean dumping ( ) If others, specify ___________
I. Hazardous Waste Management
Method of disposal (specify): _______________________________________________________________
DENR ID Number as Hazwaste Generator: __________________ Date issued:

____________________

J. Sketch of Sampling Station

I hereby certify that the information above are true, complete and accurate to the best of my knowledge.
________________________________________
Name & Signature of the Pollution Control Officer

_____________________________________
Name & Signature of the Chief Executive Officer

Date: _______________________________

Date: ___________________________

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
Doc. No. ________
Page No. ________
Book No. ________
Series No. ________

All information contained in this application form will be held strictly confidential.

LLDA-CPD-Form 11

Issue Date: December 2017

Issue No.: 03
 
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