SCC FORM K.2 'SURUHANJAYA PERKHIDMATAN AIR NEGARA (SPAN) DECLARATION ON SCC CONTRIBUTION DETAILS BASED ON FIXED RATE (SEPTIC TANK, SEWAGE TREATMENT WORKS WITHOUT SLUDGE PROCESSING FACILITY OR STANDBY POWER GENERATOR) ANDIOR SPECIFIC BUILDING lrmpertant Notes: 1. ThisSCC FORM K-2 consist of six sections. All sections need to be fillup exceot for section (3) f not relevant. 2 For section (5) Table of Contribution Detal, please use separate sheet If required. Please affix rubber stamp of ‘he Company, date and initials of the Owner/Authorized Person on each sheet. 3. For section (6) Declaration, the declaration need to intial by the project owner or whoever been authorized by the developer, 7 Se (1) TITLE OF PROJECTIDEVELOPMENT (specify phase development, relevent) (2) NAME OF PROJECT OWNER / DEVELOPER (8) COMPANYNO, © © (4) CONTRIBUTION CATEGORY (please tick whicheverralovan) t= = 7 i Category Contribution Rate Tiek(¥) B._| Seplio Tank RM 120 / Population Equivalent (PE) ‘C_| "Sewage Tresirient Works _| RM 5 / Population Equivalent (PE) B._| Specie Buring Low costs ese i: RM T000 proc (D2, Goverment schooler goverment ded school I T000/ project ‘D3, Pace of worship: R100 / project ‘Dé. Community bulking: RM 1007 bulling 1S. Charitable bling RM 100 Bang ™ ConarctsSTW witht stge processing ality or sind power gereretr or Both (5) TABLE OF CONTRIBUTION DETAIL < (a) () (6) (a) 0 No. | Category Type of No. of Unit7 PET ‘SCC AMOUNT} 18/C/0} | Development! Building! — | PEVunit | Total PE (RM) Project TOTAL AMOUNT (RM) * Type of Development: Residential Commercial / Industriel / Specie Building (01 02/03 /04})/ Others —ploase specty 2 Only for Category B and * Category B and C : [Total PEx Rl120 (Category 8) or RM 5 (Catagory C)} Catagory D : (6) x ate for 11102 (8/4)?SCC FORM K-2 (6) DECLARATION We hereby certily that the details stipulated in section (5) Table of Contribution Detail In SCC Form K-2 above are true, complete and accurate. In the event of any discrepancy in the calculation of fixed rate of septic tank, sewage treatment works. without sludge processing facility or standby power generator and/or specific building in section (5) ‘Table of Contribution Detail in SCC Form K-2 resulting in insufficient amount paid hereunder with reference to Water Services industry (Sewerage Capital Contribution Fund) Regulation 2011, We hereby undertake to immediately pay all sums stil due and payable upon being notified to do so. We hereby undertake to furnish the relevant documents and evidence for the information deciared in section (5) Table of Contribution Detail in SCC Form K-2 within seven (7) days of Commission's request. Wve fully aware and acknowledge that We am/are subjected to Section 130 Water Services Industry ‘Act 2006 (Act 655) where enforcement action can be taken by the Commission if the documents, Information or details as provided in section (5) Table of Contribution Detail in SCC Form K-2 of this form is false or misleading. Signature of Owner/Authorized Person Name (in block letters): IC or Passport No: Date: