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Self Monitoring Report
LLDA report form for monitoring
Your Browser Doesn't Support Canvas. Showing the Text Content of the PDF Instead: LAGUNA LAKE DEVELOPMENT AUTHORITY
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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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
Pg 4 of 8
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
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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
Pg 8 of 8
