Application Form for Permit to Operate (PTO) Air Pollution Source Installations (1).doc

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  po  PPLIC TION FOR “PERMIT TO OPER TE” IR POLLUTION SOURCE INST LL TIONS( PSI) Type: New Renewal Extension Change of Ownership Change of Name Modification 1. General Information: Name of Enterprise:  Address: Name of Establishment:  Address: TIN: Nature of Business: Nature of Ownership: Single Proprietorship Partnership Corporation Authorized Capital: Paid Up Capital: Date of Start of Operation Name of CEO: _______ Tel. No._ Fax No.: Total Employees: Office: Production Office Operation: hrs/day days/wk Production Operation: hrs/day days/wkLand Area Occupied: m 2 Open Area: m 2 Owned Leased SharedClassification: Industrial Commercial Residential Agricultural 2. Raw Materials & Product Information Not Applicable Raw MaterialsQuantityProductsQuantity3. List of APSI APSIControl Facility I hereby certify that the above information are true and correct to the best of my knowledge. Done this ___________ day of .  ____________________________________ _ __________________ _________ Name and Signature of the Pollution Control Officer Chief Executive Officer  SUBSCRIBED AND SWORN to before me a Notary Public, this ____day of _________, affiant exhibiting to mehis/her Community Tax Receipt No. ______________, issued at ______________, on ___________ _. FeesAmountDate PaidOfficial Receipt No.FilingPD 1856Permit Assessed by: Application No.   JSO/ Cye ‘08   Republic of the Philippines Department of Environment and Natural ResourcesEnvironmental Management Bureau-National Capital Region 5/F Hizon Bldg., Quezon Avenue, Quezon City  AQSFN-04  INSTRUCTIONS 1.Fully accomplish this form and complete all the supporting documents indicatedhereunder. Submit all documents in triplicate copies to our Air Quality ManagementSection of the Pollution Control Division for screening, assessment of fees, and issuanceof “Order of Payment”.2.Pay to the Cashier Section the corresponding amount indicated in the “Order of Payment”and present the Official Receipt to Air Quality Management Section for recording andnotation of your application.3.Submit your application to the Records Unit and ask for your receiving copy.Your application shall be acted upon with twenty five (25) working days and you shall beinformed of our action accordingly. Types of ApplicationDocuments Required  NewItem Nos.  ,  ,  ,  , &    Additional/ModificationItem Nos.  ,  ,  ,  , &   Change of Name/OwnershipItem Nos.  ,  ,  , &   RenewalItem Nos.  , &    Supporting Documents    Engineer’s Report with at least containing the following:  Description of processes including the amount of raw materials & finished products, allthe emissions into the atmosphere and or the material balance;  List of APSI and corresponding air pollution control facility (APCF) with completespecifications;  Discussion of APSI & APCF showing the process/mode of operation, design criteria &efficiencies of the APCF, the quantities & types of pollutants in the final emissions.  Pollution loading of the regulated air pollutants in tons/year.    Drawing requirements in 50cm x 90 cm paper signed by the President/General Manager and duly signed and sealed by PME/Ch E or any appropriate engineer.  Vicinity Map;  Plant & Machinery Layout showing the connection of the APSI to APCF;  Plan & elevation drawings of each APSI & APCF.    Copy of the Certificate of Accreditation of the Pollution Control Office, or appointment/designation as such by the Managing Head.    Environmental Compliance Certificate (ECC) or Certificate of Non-Coverage (CNC) copy.    Source Emission Test Requirement (if required).    Copy of Recent “Permit to Operate” issued by the Office.    Copy of SEC Registration Certificate & Articles of Incorporation    Copy of DTI Registration Certificate    Proof of compliance to permit conditions (if required).
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