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LLDA Clearance Application Form (MS Word Format)
This document is an application form for clearance from the Laguna Lake Development Authority (LLDA) for development plans/projects in the Laguna de Bay region. It requests information about the applicant, their business activity and description, water supply, wastewater generation, and treatment. Specifically, it asks for details like the applicant's name, address, type of business, production capacity, employment information, water sources, wastewater volumes, and treatment/disposal methods. The authorized representatives must sign the application, certifying the accuracy of the information provided.
LLDA Clearance Application Form (MS Word Format)
- 1. LAGUNA LAKE DEVELOPMENTAUTHORITY National Ecology Center, East Avenue Diliman, Quezon City Tel. Nos.:332-2346, 376-4039, 376-4072, 376-4049, 376-4061 CLEARANCE APPLICATION FOR DEVELOPMENT PLAN/PROGRAM/PROJECT IN THE LAGUNA de BAY REGION LLDA CLEARANCE AMENDMENT EXEMPTION EXPANSION PART I – APPLICANT INFORMATION Name of Establishment: _______________________________________________________ Tax Identification Number (TIN): __________________________ Year Established: ___________ Business Address: Number and Street: _______________________________ Barangay: ______________________ City/Municipality: _________________________________ Province: _______________________ Name & Location of Project/Development: Project Name (if any): ____________________________________________________________ Number and Street: _______________________________ Barangay: ______________________ City/Municipality: _________________________________ Province: _______________________ Chief Executive Officer of the Establishment: Name: ___________________________________ Title/Designation: ______________________ Tel #: ____________ Fax #: _____________ Cel #: _____________ email add: ______________ Applicant’s Authorized Representative/Pollution Control Officer: Name: ____________________________________Title/Designation: ______________________ Name of Firm: __________________________________________________________________ Number and Street: _______________________________ Barangay: ______________________ City/Municipality: ________________ Province: _______________Tel. # :___________________ Fax #: _________________ Cel. #: ________________ email add: ________________________ PART II – BUSINESS ACTIVITY DESCRIPTION I. Business Activity: _______________________________ Production Capacity (allowed per ECC): ________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ (continuation at the back) LLDA-CPD-Form 01 Issue Date: April2015 Issue No.: 01
- 2. A. Industrial Establishment/InfrastructureProjects and other similar project Capital Investment (Authorized Capital Stock): PhP________________________ Total Project Cost: _____________________________ B. Agro-Industrial Establishment Capacity (Maximum No. of Heads): ___________________________________________ C. Housing Development, Institution, Hospital, Commercial Establishments, Parks, Golf Course warehouse/storage facilities, etc. Gross Floor Area (sq.m): __________________ Total Lot Area (sq.m): ________________ For Townhouses/Villas/other cluster housing units (total no. of units): _________________ D. Other Projects (Land Transport Terminal/Parking Areas) No. of vehicle slots: ___________________ II. Employment and Operation Information Total Employment (number of workers) Operational Schedule/Time Production: ________________ No. of hours/day: _________ shifts/day: _____ Non-Production: ____________ No. of days/month: _______________ PART III – WATER SUPPLY, WASTEWATER GENERATION, TREATMENT AND DISPOSAL Sources of Water Supply MWSI/MWCI ( ) Local Water District ( ) Deepwell ( ) Laguna de Bay ( ) Rivers ( ) Others ( ) Total Water Consumption (m3 /day): ____________________ Wastewater Generation, Treatment and Disposal Total Volume of Wastewater Discharge (m3 /day): ___________________ Method of Treatment: _________________________________________ Disposal: ____________________________________________________ I certify that the information above are true, complete and accurate to the best of my knowledge. _________________________________________ _______________________________ Signature of Representative/Pollution Control Officer Signature of 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 strictlyconfidential. LLDA-CPD-Form 01 Issue Date: April2015 Issue No.: 01