Preparation of Rights-Based Municipal Water Supply, Sewerage and Sanitation Sector Plans (MW4SPs) Page 1 of 2

Data Form: Level 3 Water Supply Facility/System

Region/Province: ______________________ Municipality: ___________________________
Data on Existing Level 3 Water Supply Facility/System
Instructions: This form is intended for existing Level 3 Water Supply Facility/System operating within the Municipality.
One form per Water Supply Service Provider (ie. Water District, LGU Run System, BWASA, Private System)

Form No. :_______

Name of Interviewer: ___________________________ Date of Interview : ____________________________
Department/Office: ___________________________ Data Source/s : ____________________________
Name/Position/Office

I. Name of Level 3 Water Supply Service Provider: ____________________________________

II. Details of Water Source/s (list down all sources currently being utilized by the water service provider in the table below)
Water Location With Water
No. Source Type* Capacity Geographical Coordinates Permit?
Name of Barangay
(Liters/sec) Longitude Latitude (Yes/No)
1
2
3
4
5
Notes: *Source Type: 1. Spring, 2 Deep Well (>20m deep bored well), 4. Shallow Well (<20m deep bored well), 5. Dug Well (shallow large diameter well), 6. Surface Water (creek), 7.
Surface Water (river), 8. Surface Water (lake). Use additional pages if there are more than Five (5) sources

III. Details of Water Service Coverage/Concession Area (list down all barangays covered by the water supply service provider)
Customer Details
Average
(Household Connections only) Service Collection
Usage per
No. Name of Barangay Served No. of No. of Operation Efficiency
Population HH
Individual Connection/s (m3 / month) (hours/day) (in %)
Served
HH Served with Meter
1
2
3
4
5
Notes: Use additional pages if there are more than Five (5) barangays being served; HH: Household, < : greater than, > : less than
Preparation of Rights-Based Municipal Water Supply, Sewerage and Sanitation Sector Plans (MW4SPs) Page 2 of 2
Data Form: Level 3 Water Supply Facility/System
Region/Province: ______________________ Municipality: ___________________________
IV. Details of Service Operation

4.1 Water Treatment (mark all applicable boxes)

Gas Chlorination Hypo-Chlorination Sedimentation Filtration Others (specify)

4.2 Water Quality Problem (mark all applicable boxes)

Odor Color Turbidity Iron Manganese Chloride/Salinity Fecal Coliform Others (specify)

4.3 Water Quality Test/s Being Conducted (mark all applicable boxes)

No Test being conducted Bacteriological Physical Chemical Others (specify)

4.4 Water Quality Test Schedule / Frequency (mark applicable box)

Daily Weekly Monthly Quarterly Yearly Once every 3 months Once every 2 months

Others (specify)

4.5 Tariff Schedule (Household Connections only)

Mark this Box if no Tariff imposed on Consumers

First 10 cubic meters : _________ Php/cubic meter 31 to 40 and cubic meters : _________ Php/cubic meter

11 to 20 cubic meters : _________ Php/cubic meter 40 and above : _________ Php/cubic meter

21 to 30 cubic meters : _________ Php/cubic meter