Public Disclosure Authorized
ANNEX G
GENERIC INITIAL ENVIRONMENTAL EXAMINATION (IEE) CHECKLIST REPORT
For
Project name or Title
This Generic IEE Checklist Report shall be used as the interim pro-forma EIA
Report requirement for projects to be located within Environmentally Critical Areas
Public Disclosure Authorized
(ECA) where a customized IEE Checklist Report Form has not yet been developed
but are required IEE Checklist Report Form or IEE Report per existing guidelines
For ECC applications, this IEE Checklist Report shall be submitted with:
Proof of Compatibility with the existing Land Use Plan
Proof of Authority over the Project Site
Accountability Statements of Proponent (see attached form) and the Preparer (if
any, following Annexes 2-22 of Revised Procedural Manual for DAO 2003-30)
Photographs or plates/vicinity map of the project site showing impact areas and
affected areas and communities
Duly Accomplished Project Environmental Monitoring & Audit Prioritization
Scheme (PEMAPS) Questionnaire (see Annex 2-7d of Revised Procedural Manual for DAO
Public Disclosure Authorized
2003-30)
(No other documents shall be required as pre-requisite to ECC applications per DENR MC 2010-14)
Read the questions carefully and write the required information on the blank spaces
provided or otherwise check () the appropriate boxes □ or parenthesis ( ). Boxes
with check marks () are automatically required. Use additional sheets if necessary
and indicate this in the appropriate space.
Project proponents are strongly discouraged to engage the
services of consultants/facilitators/preparers to accomplish/fill-up
the IEE Checklist Report Form. The Report Forms have been
designed to be user-friendly.
Furthermore, EMB Regional Office is required to complete the
Public Disclosure Authorized
processing of an ECC application using the IEE Checklist Report
within twenty (20) working days upon receipt for completed/duly-
accomplished form.
Misleading or erroneous answers are basis for legal actions and/or denial of ECC
issuance.
PROJECT FACT SHEET
Project Name: _______________________________________________________
Project Location: _______________________________________________________
Total Project Land Area: _______________________________________________________
Total Project/Building
Footprint Area _______________________________________________________
(Area actually utilized)
Project Proponent: _______________________________________________________
_______________________________________________________
Office Address:
Generic IEE Checklist Report Form
Contact Person: _______________________________________________________
Designation: _______________________________________________________
Contact Number/s
Landline : _______________________________________________________
Fax Number: _______________________________________________________
Mobile : _______________________________________________________
E-mail Address: _______________________________________________________
I. PROJECT DESCRIPTION
1.1 PROJECT LOCATION AND AREA: Street Name, Barangay, and Municipality/City, Province
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
See attached vicinity map/s and photographs of the project site and site development/layout plan.
Geographic coordinates of the project area (Preferably use WGS 84 datum, otherwise specify datum
used).
Perimeter/Boundary points
Longitude Latitude
(based on OCT/TCT/etc)
1.2 PROJECT COMPONENTS
Area (sq. m.) / Specification/
Facilities No. of Units
Capacity Description / Remarks
Support Facilities (e.g. emergency
generators, boilers, etc.)
Admin support (e.g., canteen, office,
clinic, quarters, etc.)
Water source / supply
Waste water management Facility
Solid waste management facility
Drainage system
(Please list facilities by module/grouping. Use additional sheets if needed)
1.3 UTILITIES/REQUIREMENTS (Operation Phase):
Utilities Source Estimated Demand/Consumption
Power/Electricity
KWh
(Total)
Power/Electricity
(From Renewable Energy KWh
Sources)
Water
(Total)
(Fill-up table below if water is Cubic meters/day
not obtained from the local
water utility)
Water
(Rainwater Collection Cubic meters/day
System)
Generic IEE Checklist Report Form
Water Source
[ ] ground water [ ] well [ ] spring [ ] others: ____________________________
[ ] Surface water [ ] river [ ] lake [ ] others: ____________________________
Location of water source
__________________________________________________________________________
(Sitio/Zone, Barangay, Municipality/City, Province, Region)
Energy/Water Efficiency
Utilities Estimated Savings Proposed Efficiency/Conservation
Measures
Power/Electricity KWh
Water Cubic meters/day
1.4 MANPOWER
a. Construction Phase
Manpower Expertise/Skills Total
Requirement
b. Operation Phase
Manpower Expertise/Skills Total
Requirement
1.5 INDICATIVE PROJECT COST
Project Cost (PhP): ____________
Generic IEE Checklist Report Form
II. ENVIRONMENTAL IMPACTS AND MANAGEMENT PLAN
Possible Environmental/ Baseline Environment Preventive/ Mitigating Measures Monitoring Parameters/ Cost of Mitigation/ Monitoring
Social Impacts Implementation
LAND
Consistency with land Current land use w/in 1km radius See attached proof of compatibility with
use (as per zoning ordinance): land use
Residential
Commercial/ Institutional
Industrial
Agricultural/ Recreational
Protected Areas
Others, specify
___________________
Actual land uses w/in 1km radius:
Residential
Commercial/ Institutional
Industrial
Agricultural/ Recreational
Protected Areas
Others, specify
___________________
Disturbance to wildlife Existing vegetation in the area: Compliance with conditions of DENR/LGU Annual inspection of area Cost integrated in the
due to vegetation Forestland SLUP, Tree Cutting Permit, ROW, PCA replanted/ revegetated construction /operation cost
clearing Marshland
Permit
Grassland
Limit land clearing as much as possible
Mangrove
Provide temporary fencing for vegetation
that will be retained
Wetland Promote restoration of damaged or
Others, specify destroyed vegetation where possible (e.g.,
____________________ tree planting);
Generic IEE Checklist Report Form
Possible Environmental/ Baseline Environment Preventive/ Mitigating Measures Monitoring Parameters/ Cost of Mitigation/ Monitoring
Social Impacts Implementation
Change in surface Slope: Provide erosion control and slope Regular inspection of slope Slope/ Erosion Control
landform/ topography/ flat (0-3%) protection measures protection measures in Cost: ___________
terrain/slope gently sloping to rolling (3-18%) Designate a Spoils Storage Area, with erosion-prone areas Others, specify
steep (>18%) topsoil set aside for later use and allow Regular inspection for new ____________
Soil Erosion maximum re-use of spoils eroded areas near the site
Construction during dry season Others, specify
Stabilization of embankment with grasses ___________
or other soil cover
Others, specify
____________
Is the project site located in an area Compliance with the DENR Administrative
identified by MGB/PAG-ASA/ Order No. 2003-30 and DENR
PHIVOLCS as hazard prone? Administrative Order No. 2000-28,
Yes Implementing Guidelines on Engineering
Geological and Geo-hazard Assessment
No (EGGA).
Soil/Land contamination Existing soil type in the area: Implementation of the Ecological Solid Daily inspection of Cost integrated in the
due to improper solid sandy Waste Management Plan (ESWMP) waste/recycling bins for construction /operation cost
waste disposal
clay Set-up temporary fence around the segregation
sandy-loam construction area Daily inspection for presence
Others, specify
Implement re-use and recycling of waste of mixed garbage in the
materials facility
____________
Implement proper segregation, collection Weekly inspection of waste
and disposal of domestic wastes in accumulated
designated areas Others, specify
Provide receptacles / bins for solid wastes _____________
Coordinate with the municipal / city waste
collectors
Engage third party company for waste
collection
Others, specify ________________
Generic IEE Checklist Report Form
Possible Environmental/ Baseline Environment Preventive/ Mitigating Measures Monitoring Parameters/ Cost of Mitigation/ Monitoring
Social Impacts Implementation
Impairment of visual Presence of visually significant
landforms/landscape/structures?
Implement landscaping and other Regular inspection of Cost integrated in the
aesthetics beautification measures landscaping and other construction/ operation cost
Devaluation of land Yes Provide adequate buffer beautification activities
values No Compensate adjacent property owners Regular monitoring of buffer
zones
Others, specify
Regularly monitor
________________
presence/absence of
complaints from adjacent
property owners
WATER
Increased siltation due Specify nearest/receiving water Set-up proper and adequate sanitary Regular (ocular) inspection of: Cost integrated in the
to project activities body:
____________________________
facilities Drainage / canal systems construction/ operation cost
Water quality Strictly require the contractor and its Water treatment facility (i.e.,
degradation workers to observe proper waste disposal grease trap, septic tank, etc.)
Distance to nearest/receiving water
Others, specify body:
and proper sanitation
___________________ 0 to less than 0.5 km
Strictly observe proper waste handling and Quarterly monitoring of the
disposal following:
0.5 to 1 km
Provision of wastewater treatment facility pH
More than 1 km (e.g. septic tank, oil and water separator, TSS concentration
etc.)
BOD
If nearest/receiving water body is
fresh water, specify classification:
Set up silt trap/stilling ponds to minimize
Total Coliform
downstream siltation
AA
Provision of three-chambered septic tank Color
A for domestic sewage Oil and Grease
B Provide ring canals around fuelling tanks/
C motorpool/ maintenance areas
D Others, specify
___________
Generic IEE Checklist Report Form
Possible Environmental/ Baseline Environment Preventive/ Mitigating Measures Monitoring Parameters/ Cost of Mitigation/ Monitoring
Social Impacts Implementation
If nearest/receiving water body is
coastal or marine water, specify
classification:
SA
SB
SC
SD
Current Water Use:
Fishery
Tourist Zone / Park
Recreational
Industrial
Agricultural
Distance of project area to the
nearest well used:
0 to less than 0.5 km
0.5 to 1 km
More than 1 km
Use of the nearest well:
Drinking/Domestic
Industrial
Agricultural
Generic IEE Checklist Report Form
Possible Environmental/ Baseline Environment Preventive/ Mitigating Measures Monitoring Parameters/ Cost of Mitigation/ Monitoring
Social Impacts Implementation
Competition in water Size of population using receiving
surface water:
Implement rainwater harvesting and similar Regularly monitor Cost integrated in the
use measures as an alternative source of water presence/absence of construction/ operation cost
Depletion of water ≤ 1,000 persons Observe water conservation measures;
complaints
resources >1,000 and ≤ 5,000persons Careful selection of project site to avoid
Regular coordination with
>5,000person disruption of traditional water uses
concerned agencies
Obtain Water Permit from NWRB
Regularly monitor
Available/nearest water source. occurrences of water
Deepwell
Improve efficiency of water supply and shortages
distribution system Others, specify
Water district/LGU Others, specify ____________
Surface water _____________________
Others, specify
________________________
Increased occurrence Is the project site located in an area
identified by MGB/PAG-ASA as
Use appropriate design for project facilities Regularly monitor Cost integrated in the
of flooding
flood prone? Implement appropriate drainage system
presence/absence of
complaints
construction/ operation cost
Yes Regularly remove debris and other
Regular coordination with
materials that may obstruct water flow
No concerned agencies
Use appropriate technology (e.g. raised Regularly monitor increased
hand-pumps) to protect drinking water from frequency of flooding
flood contamination
Others, specify
Others, specify
_________________
_____________________
Generic IEE Checklist Report Form
Possible Environmental/ Baseline Environment Preventive/ Mitigating Measures Monitoring Parameters/ Cost of Mitigation/ Monitoring
Social Impacts Implementation
AIR / NOISE
Air quality degradation Distance to nearest community: Properly operate and maintain all emission Regularly monitor Cost integrated in the
0 to less than 0.5 km sources (e.g. vehicles, pumps, generator, presence/absence of construction/ operation cost
0.5 to 1 km etc) complaints
More than 1 km Install when applicable, the appropriate air
Regular (ocular) inspection of:
pollution control device/s
Strictly enforce good housekeeping Absence of white or black
practices smoke from vehicles,
heavy equipment and
Control vehicle speed to lessen generator
suspension of road dust
Presence of truck cover
Conduct water spraying to suppress dust during deliveries
sources and minimize discomfort to nearby
residents
Use covered vehicles to deliver materials
that may generate dust
Other, specify
___________________
Nuisance due to noise Distance to nearest community: Properly operate and maintain all noise Regularly monitor Cost integrated in the
generation 0 to less than 0.5 km sources (e.g. vehicles, pumps, generator, presence/absence of construction/ operation cost
0.5 to 1 km etc) complaints
More than 1 km Install when applicable, the appropriate Regular monitoring of buffer
noise control device/s (e.g., mufflers, zones
silencer, sound barriers, etc.)
Implement appropriate operating hours
Provide adequate buffer and/or planting of
trees
Others, specify
______________________
Generic IEE Checklist Report Form
Possible Environmental/ Baseline Environment Preventive/ Mitigating Measures Monitoring Parameters/ Cost of Mitigation/ Monitoring
Social Impacts Implementation
PEOPLE
Displacement of Provide relocation/disturbance Regularly monitor Cost integrated in the
residents in the project compensation packages presence/absence of construction/ operation cost
site and within its Prioritize local residents for employment complaints
vicinity
Promptly pay local taxes and other Regular coordination with
Displacement of financial obligations LGU
Indigenous People Size of population of host barangay: Regular coordination with LGU Others, specify
Enhanced employment ≤ 1,000 persons Prior consultation & coordination to
_________________
and/or livelihood
opportunities >1,000 and ≤ 5,000persons minimize disruption on daily domestic
activities & respect for IP rights and
Reduced employment >5,000person
cultural practices
and/or livelihood
opportunities Classification of host barangay: Ensure participation of IPs in consultations
and dialogues
Urban
Increased revenues for
LGU Rural
Provide appropriate traffic/warning signs,
lighting, etc
Disruption/Competition
Available services within/near the Others, specify
in delivery of public
host barangay: ________________
services (e.g.,
education, peace and Schools (e.g. elementary, high
order, etc.) school, college)
Enhanced delivery of Health facilities (e.g., clinics,
public services (e.g., hospitals, etc.)
education, peace and
order, etc.)
Peace and order (e.g., police
outpost, brgy. Tanod, etc.)
Increase in traffic Recreation and sports facilities
volume and worsening
of traffic flow Others, specify
_____________________
Impacts on community Regular coordination with LGU Presence/Absence of Cost integrated in the
health and safety Provide appropriate warning signs, lighting complaints construction/ operation cost
Others, specify and barricades, whenever practicable Regular coordination with
_______________ Observe proper housekeeping LGU
Generic IEE Checklist Report Form
Possible Environmental/ Baseline Environment Preventive/ Mitigating Measures Monitoring Parameters/ Cost of Mitigation/ Monitoring
Social Impacts Implementation
Provide on-site medical services for any Regular submission of reports
emergency. to concerned agency
Participate in public awareness programs Others, specify
on health and safety _________________
Implement appropriate safety programs for
both community and workers
Strictly comply with fire, safety and similar
regulatory requirements
Strictly comply with requirements of RA
6969
Others, specify
______________________
Generic IEE Checklist Report Form
III. ABANDONMENT /DECOMMISSIONING/REHABILITATION POLICIES AND
GENERIC GUIDELINES (if Applicable)
Project Life or Service: ___________ years
Provide description of the Abandonment activities, such as, dismantling and waste
disposal.
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
IV. INSTITUTIONAL PLAN FOR EMP IMPLEMENTATION
Organization Chart:
Generic IEE Checklist Report Form
Attach drawing/plan of waste water treatment facility (with dimensions and
descriptions)
Generic IEE Checklist Report Form
Attach drawing/plan of air pollution source and control installations (with
dimensions and descriptions)
Generic IEE Checklist Report Form
SWORN STATEMENT OF ACCOUNTABILITY OF THE PROPONENT
This is to certify that all the information and commitments in this Initial
Environmental Examination (IEE) Checklist Report are accurate and complete to
the best of my knowledge.
By the authority vested in me by the ____(Company Name) as
___(Position/Designation), I hereby commit to ensure implementation of all
commitments, mitigating measures and monitoring requirements indicated in this
IEE Checklist Report as well as the following:
Conform to pertinent provisions of applicable environmental laws
e.g., R.A. No. 6969 (Toxic Substances and Hazardous and Nuclear
Wastes Control Act of 1990), R.A. No. 9003 (Ecological Solid
Waste Management Act of 2000), R.A. No. 9275 (Philippine Clean
Water Act of 2004), and R.A. No. 8749 (Philippine Clean Air Act of
1999).
Abide and conform to LGU development plans and guidelines.
Promptly pay local taxes and other financial obligations.
Regularly submit reports to concerned agencies.
I hereby bind myself to answer any penalty that may be imposed arising
from any misrepresentation or failure to state material information in this IEE
Checklist.
In witness whereof, I hereby set my hand this ____ day of __________ at
______________________.
__________________________
NAME OF PROPONENT HEAD
(Position)
(Company Name)
SUBSCRIBED AND SWORN TO before me this _____ day of ____________ 201__, affiant
exhibiting his/her Community Tax Certificate No. ___________________ issued at
______________________ on __________________________.
Doc. No. ____________________
Page No. ____________________
Book No. ____________________
Series of ____________________
Generic IEE Checklist Report Form
