Professional Documents
Culture Documents
Self Monitoring Report
Self Monitoring Report
Note: SMR is deemed acceptable if the regional office does not issue
“Notice of Deficiency”
Evaluation of SMR :
Consistent with the requested information
e-mail address
Name :
Pollution Control Officer
Tel # : ____________________ Fax # : ______________
e-mail address : _________________________________
We hereby certify that the above information are true and correct.
Name/Signature of CEO/ President Name/Signature of PCO
MODULE 1. General Information
Operation
Operating # of shift/day
Operating hours/day days/week
Average
Maximum
Operation/Production/Capacity
Average Daily
Production Output Total Production
Output this
Quarter
Total Water TotalElectric
Consumption this Consumption this
Quarter ( cubic Quarter
meters)
Please use additional sheet/s if necessary
Other Information
Manner of handling
hazardous wastes Storage on-site Treatment on-site
Storage off-site Treatment off-site
Changes in Safety Yes (please attach copy of revised plan)
Management System No
Yes ( please attach copy if not submitted/included in previous report/s or had
been revised)
Chemical Substitute
Plan No
Waste Storage, Treatment and Disposal: (please fill-up one per HW)
HW No,: ________________ __________________________________________________________________________
HW Details Qty of HW Treated: ________________________________________________Unit:___________________________ _______
TSD Location : ___________________________________________________________ __________________ ______
Type of
Transport Storage Time Table
Wastes Date of
HW Number Permit/Date Valid until Quantity Container/ for
Generator Transport
of Issue # of Treatment
containers
Type &
Type of
Transport Quantity of
Type of Wastes Date of Treatment or
HW Number Permit/Date Quantity Recycled or
Wastes Generator Transport Recycling
of Issue Treated
Process
Product
FORMAT of (MODULE 2C.)
Residual Wastes Generated from the Treatment and/or Recycling Operation:
Type of
Process by
Storage
Type of HW which the Disposal Time Table
Quantity Container/
Wastes Number Wastes is Option for Disposal
# of
Generated
containers
It is intended to provide
information related to compliance
on R.A 9275
Outlet
Location of the Outlet Name of Receiving Water Body
Number
1
2
3
4
5
Outlet No.
Effluent Oil & ________
BOD TSS Temp rise
DATE Flow Rate Color pH Grease (name)
(mg/L) (mg/L) (ºC)
(m3/day) (mg/L) (unit)
Summary of APSE/APCF
Quantity # of hrs of
Fuel Burning Equipment Location Fuel Used
Consumed operations
1.
2.
3.
4.
5.
6.
Pollution Control Facility Location # of hrs of operations
1.
2.
3.
4.
FORMAT of (MODULE 4.)
MODULE 4: R.A. 8749 (Air Pollution)
Cost of Treatment
Month 1 Month 2 Month 3
Cost of Person
employed, (salary)
Total Consumption of
Water (cubic meters)
Total Cost of chemicals
used (e.g., activated
carbon, KMnO4)
Total Consumption of
Electricity (KwH)
Administrative and
Overhead Costs
Cost of operating in-
house laboratory, if any
Improvement or
modification, if any.
(Description)
Cost of improvement of
modification
Description/Location
of PCF
________ ________ ________ ________
Flow Rate CO NOx Particulates
DATE (name) (name) (name) (name)
(Ncm/day) (mg/Ncm) (mg/Ncm) (mg/Ncm)
(mg/Ncm) (mg/Ncm) (mg/Ncm) (mg/Ncm)
Description/Locati
on
of Monitoring
Station
______ ______ ______ ______
Particulat
Noise CO NOx __ __ __ __
es
DATE Level (mg/Nc (mg/Nc (name) (name) (name) (name)
(mg/Ncm
(dB) m) m) (mg/Nc (mg/Nc (mg/Nc (mg/Nc
)
m) m) m) m)
Description/Location
of Sampling Station
________ ________ ________ ________ ________ ________ ________ ________
DATE (name) (name) (name) (name) (name) (name) (name) (name)
(unit) (unit) (unit) (unit) (unit) (unit) (unit) (unit)
Status of
ECC Condition/s Compliance Actions Taken
Yes No
1.
2.
3.
4.
Please use additional sheet/s if necessary.
Status of Implementation
Enhancement/Mitigation Measures Actions Taken
Yes No
1.
2.
3.
4.
Please use additional sheet/s if necessary.
FORMAT of (MODULE 5.)
Solid Waste Characterization/Information:
Findings and
Date Area/Location Actions Taken Remarks
Observation
Personnel/Staff Training
___________________ _________________________________
Name/Signature of CEO Name/Signature of PCO
SUBSCRIBED AND SWORN before me, a Notary Public, this ________ day of
______________________, affiants exhibiting to me their Community Tax Receipts: