Sample Self Monitoring Report
Sample Self Monitoring Report
Sample Self Monitoring Report
Reference No.
DENR Permits/Licenses/Clearances
Environmental
Permits
Laws
A/C No.
P.D. 984
R.A. 9275
PD 1586
RA 6969
RA 8749
PO No.
PO No.
ECC 1
ECC 2
ECC 3
DENR
Registry ID
CCO Registry
Importer
Clearance No.
Permit to
Transport
A/C No.
PO No.
Date of
Issue
Expiry date
POA-
Page 1 of 9
Reference No.
Operation
Average
Maximum
Operating hours/day
8
10
Operating days/week
7
7
# of shift/day
1
1
Operation/ Production/capacity:
Average Daily Volume
Sales Output (Liters)
Premium Gasoline
450 Liters
Premium Gasoline
40,500 liters
Regular Gasoline
500 Liters
Regular Gasoline
45,000 liters
Diesel Fuel
Total water
Consumption this
Quarter (cubic
meters)
625 Liters
Diesel Fuel
Total Electricity
Consumption this
Quarter (KWH)
56,250 liters
30 cu. m.
2,750 kwhr
Page 2 of 9
Reference No.
0.5
Process
wastewater
(cubic meters/day)
Others:
__________
(cubic meters/day)
Wash water, floor
(cubic meters/day)
None
None
None
None
None
None
None
None
None
None
None
None
None
None
None
Third Party
Testing
None
None
None
None
None
None
Page 3 of 9
Reference No.
Page 4 of 9
Reference No.
Summary of APSE/APCF
Process Equipment
# of Hrs of
Operations
920
920
920
Location
Refilling Station
Refilling Station
Refilling Station
Fuel used
Quantity
consumed
# of Hrs of
Operations
Diesel Fuel
9 Liters
Location
Front corner of the refilling station
# of Hrs of
Operations
920
Cost of treatment
October
November
December
none
none
None
Total consumption of
water (cubic meters)
60
45
60
n/a
n/a
n/a
Used (e.g.,activated)
Carbon, KMnO4)
n/a
n/a
n/a
Total consumption of
electricity (KWH)
n/a
n/a
n/a
Administrative and
overhead costs
n/a
n/a
n/a
Improvement or
modification, if any.
(description
none
none
None
Cost of improvement of
modification
none
none
None
Cost of person
Employed (salary)
Page 5 of 9
Reference No.
TOC
Exhaust
Crankcase
0.0007
0.0012
Page 6 of 9
Reference No.
NO
Particulates
(mg/Ncm)
(Name)
(Name)
(Name)
(Name)
(mg/Ncm)
(name)
(name)
(name)
(name)
(name)
(name)
(name)
(unit)
(unit)
(unit)
(unit)
(unit)
(unit)
(unit)
Page 7 of 9
Status of Compliance
Yes
No
Reference No.
Actions Taken
Status of
Implementation
Yes
No
Actions Taken
Proper monitoring of
dispensed
fuel
against inventory.
Coordination
with
the
supplier
for
proper maintenance
of fuel dispensers
quarterly.
Yes
Yes
30 kgs
n/a
Page 8 of 9
Reference No.
MODULE 6: OTHERS
Accidents & Emergency records
Date
Area/Location
Findings and
observation
Actions
Taken
Remarks
None
Personnel/Staff Training
Date Conducted
Course/Training
Description
NONE FOR THE QUARTER
# of Personnel
Trained
I hereby certify that the above information are true and correct.
Done this _______ day of January 2016 in Laoag City, Ilocos Norte.
IMELDA B. CRISTOBAL
Pollution Control Officer
DR.MODESTY IRMINA A. CORPUZ
OWNER
SUBSCRIBED AND SWORN before me, a Notary Public, this __________ day of
__________________, affiants exhibiting to me their Government Issued ID:
Name
Govt. Issued ID
Issued at
Issued on
____________
________________
IMELDA B. CRISTOBAL
________ .
________________
______________
NOTARY PUBLIC
Page 9 of 9